Makindo Medical Notes

🧴 Levobupivacaine – Clinical Overview

💉 Levobupivacaine is the pure S(−)-enantiomer of bupivacaine. It is a long-acting amide local anaesthetic that provides potent sensory block with a lower risk of cardiotoxicity than racemic bupivacaine, while retaining similar duration of action. It is widely used for neuraxial anaesthesia/analgesia, peripheral nerve blocks, and perioperative infiltration.

⚙️ Mechanism of Action

• 🔌 Blocks voltage-gated sodium channels in neuronal membranes, preventing initiation and propagation of action potentials.
• 🧪 High lipid solubility and protein binding contribute to potency and long duration.
• 🔄 Stereoselectivity (S-enantiomer) is associated with a wider cardiac safety margin versus racemic bupivacaine.

📊 Pharmacology (At a Glance)

• 📚 Class: Amide local anaesthetic.
• ⏱ Onset: ~5–20 minutes (site and concentration dependent).
• 🕒 Duration: ~6–12+ hours (prolonged with adjuvants and in highly vascular vs. less vascular sites).
• 🧷 Protein binding: ~97%.
• ⚖️ Metabolism: Hepatic (CYP1A2, CYP3A4); inactive metabolites excreted renally.

🩺 Common Clinical Uses

• 🧍‍♀️ Neuraxial techniques: epidural anaesthesia (surgery), epidural analgesia (labour, postoperative), caudal epidural in children.
• 🦵 Peripheral nerve blocks: brachial plexus, femoral/adductor canal, sciatic, TAP, ESP, and others.
• 🩹 Local infiltration and field blocks for prolonged postoperative analgesia.

💊 Typical Concentrations and Examples

Indication	Typical Concentration / Notes
🤰 Epidural analgesia (labour/post-op)	0.0625–0.125% (often with opioid adjunct e.g., fentanyl) to favour sensory over motor block
🛏 Epidural anaesthesia (surgical)	0.25–0.5% titrated in fractionated doses to dermatomal level
🦾 Peripheral nerve block	0.25–0.5% depending on block depth/site and desired motor block
🩹 Infiltration/field block	0.125–0.25% for wound infiltration and plane blocks

⚠️ Dose limits: Follow local guidance. Max ~2 mg/kg (not to exceed ~150 mg). Reduce dose in frailty, pregnancy, hepatic impairment, or multiple techniques.

📈 Advantages and Comparators

• ✔️ Analgesic potency and duration comparable to bupivacaine.
• ❤️ Lower cardiotoxic and CNS toxicity risk than racemic bupivacaine.
• ⚖️ Compared with ropivacaine: slightly more potent, but ropivacaine may cause less motor block.

➕ Adjuvants

• 💉 Epidural: low-dose opioid (fentanyl) for enhanced analgesia.
• 🧠 Peripheral blocks: clonidine or dexmedetomidine (off-label) may prolong block.
• 🌟 Dexamethasone (IV or perineural, off-label) prolongs block duration.

🚨 Safety and Toxicity (LAST)

• ⚡ Systemic toxicity still possible – always aspirate, inject incrementally, and monitor.
• 🧠 CNS: circumoral numbness, tinnitus, metallic taste, agitation, seizures.
• ❤️ CVS: hypotension, bradycardia, arrhythmias, cardiac arrest (risk lower than bupivacaine but not zero).

🛑 Immediate management:

• Stop injection, call for help, 100% O₂, airway support, treat seizures.
• 🧴 Lipid emulsion: 1.5 mL/kg bolus → 0.25 mL/kg/min infusion (increase if unstable).
• Apply ACLS modifications (reduce adrenaline dose, avoid vasopressin).

⚠️ Contraindications & Cautions

• ❌ Absolute: allergy to amide LAs, infection at site, uncorrected hypovolaemia (neuraxial).
• ⚠️ Relative: severe stenotic valve disease, coagulopathy/anticoagulation, hepatic failure, frailty, pregnancy adjustments.
• 💊 Drug interactions: CYP1A2/3A4 inhibitors ↑ plasma levels; additive depressant effects with class I antiarrhythmics.

👶 Obstetric & Perioperative Notes

• 🤰 Widely used for labour epidurals (sensory–motor separation beneficial).
• 🍼 For Caesarean, fractionated epidural top-ups with close monitoring.
• 🦵 Prolonged analgesia in peripheral blocks supports opioid-sparing multimodal regimens.

📝 Practical Tips

• 📏 Always calculate dose based on weight.
• 🖥 Use ultrasound guidance for blocks to minimise dose/systemic absorption.
• ⏳ Inject incrementally, aspirating often.
• 🧴 Keep intralipid immediately available before starting large-volume blocks.

🌟 Key Takeaways

• Levobupivacaine = long-acting LA with safer cardiac profile than bupivacaine.
• Excellent for neuraxial & peripheral blocks, especially prolonged analgesia.
• LAST risk remains → vigilance, monitoring, intralipid access essential.

📚 Selected References

• 📖 Neal JM, et al. ASRA Practice Advisory on Local Anesthetic Systemic Toxicity.
• 📖 McLeod G. Levobupivacaine. Anaesthesia & Intensive Care Medicine (review).
• 📖 Comparative studies of levobupivacaine vs bupivacaine/ropivacaine in regional techniques.