ROE-pi-vi-kane

Therapeutic Classification: epidural local anesthetics, anesthetics (topical/local)

• 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/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).

(analgesia)

†Duration of anesthetic block.

Contraindicated in:

• Hypersensitivity; cross-sensitivity with other amide local anesthetics may occur (bupivacaine, lidocaine, mepivacaine, prilocaine).

Use Cautiously in:

• Glucose–6–phosphate dehydrogenase deficiency, history of methemoglobinemia, cardiac or pulmonary disease, or concurrent exposure to oxidizing agents (or metabolites of these agents) (↑ risk of methemoglobinemia)
• 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
• Pedi: Safety and effectiveness not established in children; infants <6 mo (↑ risk of methemoglobinemia).

CV: CARDIOVASCULAR COLLAPSE, arrhythmias, bradycardia, chest pain, hypertension, hypotension, tachycardia.

Derm: pruritus.

F and E: hypokalemia, metabolic acidosis.

GI: nausea, vomiting.

GU: urinary retention.

Hemat: METHEMOGLOBINEMIA, anemia.

MS: chondrolysis.

Neuro: circumoral tingling/numbness, paresthesia , SEIZURES, anxiety, dizziness, headache, rigors.

Resp: dyspnea.
Misc: (INCLUDING ANGIOEDEMA AND ANAPHYLAXIS)HYPERSENSITIVITY REACTIONS , fever.

Drug-Drug:

• Additive toxicity may occur with concurrent use of other amide local anesthetics (includinglidocaine, mepivacaine, and prilocaine).
• Fluvoxamine, amiodarone, ciprofloxacin, and propofol may ↑ the effects of ropivacaine.
• Concurrent use of acetaminophen, benzocaine, bupivacaine, chloroquine, cyclophosphamide, dapsone, flutamide, hydroxyurea, ifosfamide, metoclopramide, nitrofurantoin, nitroglycerin, nitroprusside, nitrous oxide, phenobarbital, phenytoin, prilocaine, primaquine, procaine, quinine, rasburicase, ropivacaine, sulfonamides, tetracaine, and valproate may ↑ risk of methemoglobinemia; monitor closely.
• ↑cardiac depression and toxicity with phenytoin, amiodarone, quinidine, procainamide, or propranolol.
• Cimetidine, azole antifungals, clarithromycin, erythromycin, fluoxetine, fluvoxamine, nefazodone, paroxetine, protease inhibitors, propofol, ritonavir, verapamil, and propranolol may ↓ metabolism and ↑ risk of toxicity.
• Lidocaine may ↑ levels of calcium channel blockers, certain benzodiazepines, cyclosporine, fluoxetine, lovastatin, simvastatin, mirtazapine, paroxetine, ritonavir, tacrolimus, theophylline, tricyclic antidepressants, and venlafaxine.
• Effects of lidocaine may be ↓ by carbamazepine, phenobarbital, phenytoin, and rifampin.

Surgical Anesthesia

• 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.

(Generic available)

• Solution for injection (preservative-free): 2 mg/mL (0.2%); 5 mg/mL (0.5%); 7.5 mg/mL (0.75%); 10 mg/mL (1%);
• Premixed infusion: 2 mg/mL (0.2%); 5 mg/mL (0.5%);

• 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 arrhythmias). 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.

• Ropivacaine should be administered by clinicians well versed in the diagnosis and management of dose-related toxicity and other potential acute emergencies from the block to be employed, and only with immediate availability of oxygen, other resuscitative drugs, cardiopulmonary resuscitative equipment, and personnel resources needed for management of toxic reactions and related emergencies.

• 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.
• Advise females of reproductive potential to notify health care professional if pregnancy is planned ore suspected or if breastfeeding.

• Decrease in postoperative pain without unwanted sensory or motor deficits.

Naropin

• Acute pain, acute (Indications).
• Impaired physical mobility (Adverse Reactions).