British Journal of Anaesthesia 85 (3): 3446 (2000)
Editorial II
Ropivacaine in children
Ropivacaine is the s-enantiomer of a new amide local
anaesthetic which has been extensively evaluated in adults
and older children.1 Recently, it has been used in younger
children and several studies have reported its clinical
efcacy and safety when administered for caudal epidural
analgesia,213 for lumbar epidural block,14 for peripheral
nerve blockade,15 16 and as a continuous epidural infu-
sion.1720 Pharmacokinetic parameters have been calculated
for several different age groups and the pharmacodynamics
in children are becoming clearer as clinical experience
grows. A meta-analysis of neonatal outcome after maternal
administration of ropivacaine has also been published
recently.21
Ropivacaine has several properties which may be useful in
paediatric practice, namely the potential to produce differ-
ential neural blockade with less motor block and reduced
cardiovascular and neurological toxicity.1 These features
are particularly attractive for day case surgery in children,
which is increasing in frequency.
Studies of ropivacaine in children have reported pharma-
codynamics and/or kinetics after single caudal or lumbar
epidural injection of doses between 1 and 3 mg kg1,
peripheral nerve blockade with up to 3 mg kg1, plexus
blockade, epidural infusion analgesia with up to 0.4 mg kg1
h1 via caudal or lumbar epidural catheters, and the effects
of adding clonidine or preservative-free ketamine to caudal
ropivacaine.
For single injection caudal epidural block, comparisons
between equal masses of ropivacaine and bupivacaine have
shown virtually identical proles in terms of onset time,
efcacy, duration of analgesia and incidence of motor
blockade.3 4 911 14 22 As has been demonstrated for bupiva-
caine, ropivacaine caudal blocks can be prolonged by a
factor of 2- to 3-fold by the addition of clonidine or
ketamine to the caudal injectate.23 24 A number of studies of
caudal block have compared ropivacaine with the same
volume and/or mass of bupivacaine.3 4 911 14 22 The 2 mg
ml1 concentration of ropivacaine gives results comparable
to 2.5 mg ml1 bupivacaine while 3.75 mg ml1 solution
gives less motor block than bupivacaine when equal
volumes are administered. When the same mass of
ropivacaine is given but in a larger volume than bupiva-
caine, analgesia is prolonged.9 When a larger mass of
ropivacaine is given in a similar volume, analgesia is
The Board of Management and Trustees of the British Journal of Anaesthesia 2000
prolonged when compared with bupivacaine or with
ropivacaine itself.12 The more concentrated solutions of
ropivacaine do produce motor block but the frequency,
intensity and duration is shorter than an equal mass of
bupivacaine.3 4 In a detailed study of a standard volume (1
ml kg1) of caudal ropivacaine in three concentrations (1, 2
and 3 mg ml1), the weakest solution produced a block to
L4, with a shorter duration of analgesia and no motor block.
Both 2 and 3 mg ml1 produced higher blocks to T12 with a
longer and equal duration of analgesia and motor block in
13 and 28% of children, respectively, which lasted up to 4 h.
The 2 mg ml1 solution appears to be optimal in terms of
producing adequate analgesia with an acceptable degree of
motor blockade.2
The pharmacokinetics of ropivacaine in children beyond
1-yr-old after a single injection caudal block are very
variable but are broadly similar to those in adults and no age
related effects are seen in the key kinetic param-
eters.2 5 6 8 12 13 15 After single injection blocks, the plasma
concentration proles show that peak concentrations of total
and free ropivacaine are well below the threshold for
toxicity of 0.30.9 mg l1. Free fraction seldom reaches
10%. A very small proportion of the administered dose is
excreted unchanged in the urine and most of the ropivacaine
is excreted in the urine as hydroxylated or dealkylated
metabolites. The weight-corrected values for clearance,
volume of distribution and elimination half life do not vary
with age between 1 and 12 yr.2 5 6 8 12 13 15
In younger infants, below 6 months, clearance decreases
and below 3 months, signicantly higher free plasma
concentrations (0.099 vs 0.038 mg litre1) and free fractions
(10% vs 5%) occur than in infants over 3 months old8 after a
single caudal injection of 2 mg kg1 (1 ml kg1 of 2mg ml1
solution).
For peripheral nerve blockade, a more concentrated
solution of ropivacaine, 5 mg ml1, in a volume of 0.6 ml
kg1 (3 mg kg1) has been found to be effective and safe in
children from 112 yr when administered as an ilio-inguinal
block.15 This dose and route of administration resulted in
low peak plasma concentrations of total ropivacaine.
Maximum free plasma ropivacaine concentrations at 0.02
0.14 mg litre1 were well below the toxic threshold.15
For single injection lumbar epidural administration in
infants between 1 and 12 months,14 a volume of ropiva-
 Editorial II
caine, 0.7 ml kg1 (2 mg ml1) solution produced a similar
onset, duration and efcacy to the same volume of
bupivacaine, 2.5 mg ml1.
In this issue, Hansen and colleagues7 have added to the
body of information on the pharmacokinetics and pharma-
codynamics of ropivacaine during continuous epidural
infusion in children from 3 months.7 1720 A loading dose
of 12 mg kg1 has been described,7 17 18 20 followed by a
constant rate continuous infusion of 0.4 mg kg1 h1 (0.2 ml
kg1 h1 of 2 mg ml1 solution). This has been used
successfully in children, infants and neonates although
pharmacokinetic data are limited to those over 3 months
old.7
Neonatal outcome after maternal administration of
ropivacaine by intermittent boluses or continuous infusions
compared favourably with similar doses of bupivacaine in
terms of neurological and adaptive capacity scores (NACS)
at 24 h, spontaneous vaginal delivery rates, instrumental
delivery rates and intensity of motor block.21
Popliteal fossa block has been described in children with
ropivacaine for analgesia after foot and ankle surgery in
infants and children from 6 months.16 The duration of
effective pain relief ranged from 8 to 12 h.
In summary, for single injection caudal block, a volume
of 1 ml kg1 of ropivacaine 2 mg ml1 solution (2 mg kg1)
will reliably produce analgesia for inguinal surgery with an
acceptable incidence and duration of motor block. A longer
duration of analgesia can be achieved at the expense of more
frequent and long lasting motor blockade by the use of a
larger volume of the same concentration of ropivacaine or
by using the same volume of a more concentrated solution,
to a maximum dose of 3 mg kg1. Where a longer duration is
needed with no motor block, clonidine, 2 mg kg1 or
preservative-free ketamine, 0.5 mg kg1 will prolong
analgesia some 2- to 3-fold. For ilioinguinal block a single
injection of 3 mg kg1 (0.6 ml kg1 of 5 mg ml1 solution) is
safe and effective. For continuous epidural infusion anal-
gesia, ropivacaine at a rate of 0.4 mg kg1 h1 (0.2 ml kg1 h
1
of 2 mg ml1 solution) is safe and effective. Further
research is required to dene the safe dosing limits in
neonates, young infants and less healthy children. Clearance
decreases below 6 months and protein-binding capacity in
the neonate is reduced.8 As suggested in this issue,7
reducing the dose and limiting the duration of continuous
infusions to 3648 h are recommended in neonates and
young infants until further data are available.
N. S. Morton
Royal Hospital for Sick Children
Glasgow
References
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 Editorial II
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