Sir Salimullah Med Coll J 2022; 30: 115-122

Original Article DOI: https://doi.org/10.3329/ssmcj.v30i2.61926

Outcome of Low-Dose 0.5% Levobupivacaine

(Plain) And Low-Dose 0.5% Bupivacaine (Heavy)
Combined with Fentanyl in Spinal Anaesthesia
For Transurethral Resection of Prostate:
A Comparative Study
Mohammad Ashrafur Rahman1, Md. Nazmul Islam2, Zikrul Bashir3, Nazmul Ahsan Siddiqi Rubel4,
Md. Tajul Islam5, Paresh Chandra Sarker6

Abstract:
Article information Background: Spinal anaesthesia is widely used for transurethral resections of prostate
Received: 01-03-2022
(TURP) because it allows early recognition of symptoms caused by over hydration, TURP
Accepted: 20-06-2022
syndrome, and bladder perforation. Patients undergoing TURP surgery have coexisting
pulmonary or cardiac disease.
Objective: To evaluate the outcome of the two anaesthetic agents – levobupivacaine and
bupivacaine in TURP surgery when they are combined with fentanyl.
Cite this article:
Rahman MA, Islam MN, Method: Total eighty patients were selected by inclusion and exclusion criteria, and then
Bashir Z, Rubel NAS, Islam the selected patients were randomly divided into 2 groups (40 in each). levobupivacaine
MT, Sarker PC. Outcome of group (1) was received intrathecal 0.5% levobupivacaine 5mg (1 ml) + 25 micro gram
Low-Dose 0.5% Levo- fentanyl (0.5ml) and in bupivacaine group (2) was received intrathecal 0.5% bupivacaine
bupivacaine (Plain) and heavy 5 mg(1ml) +25 micro gram fentanyl(0.5ml) slowly @1ml/10sec. Heart rate, non-
Low-Dose 0.5% Bupivacaine
invasive systolic, diastolic and mean arterial blood pressures and oxygen saturation (SpO2)
(Heavy) Combined With
were recorded immediately before intrathecal injection and every 3 min for 15 min after
Fentanyl in Spinal Anaes-
thesia for Transurethral intrathecal injection and there after every 5 minutes upto 40 minutes and at the end of
Resection of Prostate surgery.
(TURP) Surgery: A Results: All the haemodynamic variables except heart rate were almost statistically matched.
Comparative Study. Sir
Half of levobupivacaine group and 30% of the bupivacaine group achieved a sensory block
Salimullah Med Coll J 2022;
30: 115-122 up to the level of T10. Sixty percent of the levobupivacaine and 15% of the bupivacaine
group at the beginning of the surgery had modified Bromage score ‘1’. None of the
levobuppivacaine and 15% of the bupivacaine groups had a Bromage score ’3’. The recovery
from motor block was significantly earlier in the levobupivacaine group compared to that
in the bupivacaine group. Over half (55%) of the former group exhibited complete recovery
at the end of surgery as opposed to only 20% of the latter group.
Key words:
Levobupivacaine, TURP, Conclusion: For TURP surgery, a low dose of levobupivacaine with fentanyl can provide
Spinal Anaesthesia. an adequate sensory blockade and can be used as a good alternative to bupivacaine.

1. Assistant Professor (Anaesthesiology), Department of Anaesthesiology, Sir Salimullah Medical College, Dhaka.
2. Assistant Professor(Anaesthesiology), OSD DGHS,Attached; Kurmitola 500 Beded General Hospital, Dhaka.
3. Junior Consultant (Anaesthesiology), Modern District Hospital, Joypurhat. 4.Junior Consultant (Anaesthesiology),Sheikh
Hasina National Institute of Burn and Plastic Surgery, Dhaka
5. Associate Professor (Anaesthesiology),Department of Anaesthesiology,Sir Salimullah Medical College, Dhaka.
6. Professor Dr. Paresh Chandra Sarker Senior Consultant (Anaesthesiology), Delta Hospital Ltd, Dhaka.
Address of Correspondence: Dr. Mohammad Ashrafur Rahman, Assistant Professor (Anaesthesiology), Department of
Anaesthesiology, Sir Salimullah Medical College, Dhaka. ORCID: 000-0003-0806-8352
116 Sir Salimullah Med Coll J Vol. 30, No. 2, July 2022

Introduction: compare it with low dose bupivacaine when they

Despite advances in surgical and anaesthetic are combined with fentanyl in spinal anaesthesia
techniques, major surgery can still be associated for TURP surgery.
with significant postoperative undue events. The
objective of anaesthesia is to facilitate surgery at Methods and Materials:
minimal risk to the patient and to ensure optimal This prospective randomized clinical trial was
recovery following the procedure1. The excellent carried out in the Department of Anaesthesiology,
recovery profile of any anaesthetic agents Sir Salimullah Medical College Mitford Hospital
represents an important clinical benefit. Both (SSMCMH), Dhaka over a period of six months
anaesthesia and pre-anaesthetic agents can affect between march 2013 to august 2013. The study
the recovery time of patients as well as recovery was performed after obtaining the approval of the
from sensory and motor blockade. Drugs that are Ethics Committee of our Institution. Patients were
not accumulated in the body are usually beneficial selected who were aged between 50-70 years with
for early recovery and do not cause any delayed or ASA class I & II and scheduled for TURP under
recurrent adverse effects even after prolonged spinal anesthesia.Patients were excluededd as they
administration2. were having a history of significant cardiac,
For transurethral resection of prostate (TURP) pulmonary hepatic or renal diseases,ASA class>III
surgery a sensory block extending to T10 , Chronic drug or alcohol abuse, contraindications
dermatome is necessary to provide adequate of spinal anaesthesia and hypersensitivity to local
analgesia. Spinal anaesthesia for transurethral anaesthetics/ fentanyl. Patients’ informed consent
resection of prostate (TURP) operations has been was taken from each the patients or their legal
frequently used, because symptoms of over attendant. The sample size at the 5 % level of
hydration, TURP syndrome and bladder perforation significance and 80% power was calculated 80.The
can be recognized earlier. Meanwhile, short acting selected patients were randomly divided into 2
spinal anaesthesia with minimum motor block can
groups (40 in each) by card drawn method.
be useful in preventing the patients from the
complications related to delayed immobilization. Patients were not premediated before surgery.
It can be assumed that recovery and mobilization Before lumbar puncture, an intravenous (IV)
of the patients could be faster, if the motor block cannula 18G was inserted and an infusion of NaCl
was less intense. For this purpose, short acting or 0.9%(Normal Saline) /Hartmann’s solution was
low doses of local anaesthetics are preferred3.4. started @ 10ml/kg body weight within 20 minutes
Levobupivacaine has similar efficacy but an of induction. All spinal anesthesia was performed
enhanced safety profile when compared to at the level of L3-L4/L4-L5 with a 25 G Quincke
bupivacaine, a major advantage in regional type needle under aseptic condition and local
anesthesia5.6. However, very few literatures have anaesthetic skin infiltration (2% Lidocaine 1 ml),
so far reported the use of levobupivacaine in low in sitting position by the same anesthesiologist.
doses intrathecally for TURP surgery. Lee et al7 The patients were immediately turned supine.
(2003) was the first evaluate the effectiveness of
Patients in the levobupivacaine group( group I)
2.6 mL 0.5% levobupivacaine in spinal route in
received intrathecal 0.5% levobupivacaine 5 mg (1
urological surgery and found that, onset time,
degree of sensory and motor block and ml) + 25 mg fentanyl (0.5 ml) (total volume 1.5 ml),
hemodynamic changes were similar to those for and in the bupivacaine group (group II)received
2.6 ml 0.5% racemic bupivacaine. Akcaboy et al8 intrathecal 0.5% bupivacaine heavy 5 mg (1 ml)
(2011) demonstrated that 5 mg 0.5% +25 micro gram fentanyl (0.5 ml) (total volume 1.5
levobupivacaine with 25 micro gram fentanyl usage ml) slowly @ 1 ml/10sec. The drug was prepared
in spinal anaesthesia could provide adequate by an independent anesthesiologist. The
sensorial blockade without motor block, stable anesthesiologist who performed the spinal
haemodynamic profile and good patient and anaesthesia was blinded to the study groups.
surgeon satisfaction for TURP surgery. Heart rate (HR), non-invasive systolic, diastolic and
The purpose of this study is to evaluate the outcome mean arterial blood pressures (SAP, DAP, MAP)
(clinical efficacy, block quality and haemodynamic and oxygen saturation (SpO2) was recorded
effects) of low-dose levobupivacaine and also to immediately before intrathecal injection and every
Outcome of Low-Dose 0.5% Levobupivacaine & Low-Dose 0.5% Bupivacaine Mohammad Ashrafur Rahman et al 117

3 min for 15 min after intrathecal injection and bolus and these were noted. Other adverse effects
thereafter every 5 minutes up to 40 minutes and like pruritis, nausea, vomiting shivering and
at the end of surgery. Quality of anaesthesia was respiratory depression also were recorded. In case
assessed by testing for sensory and motor blockade. of anxiety, 2 mg midazolam was given an IV for
Sensory blockade was monitored with the pinprick sedation. If the patient complained of pain during
test at every 3 minutes for15 minutes, at the end operation, 25 micro gram fentanyl was
of the surgery and in the recovery room until S2 administered IV.
segment regression. Time to achieve sensory block Data processing statistical analysis:The data
of T10, maximum spread of sensory block, time to were processed and analysed using SPSS Version
two segment regression and time to S2 regression 17 (Statistical Package for Social Sciences). The
was recorded. Motor blockade was assessed based test statistics used to analyse the data were
on a Modified Bromage Scale (BMS) (as 0 = no descriptive statistics, Chi-square (c2) Probability
paralysis, able to flex hips/knees/ankles; 1 = able Test, Student’s t-Test and Repeated Measures
to move knees, but unable to raise extended legs; ANOVA. For all analytical tests, the level of
2 = able to flex ankles, unable to flex knees; 3 = significance was set at 0.05 and p < 0.05 was
unable to move any part of the lower limbs) every considered significant. The summarized data were
3 minutes for 15 minutes, at the end of the surgery presented in the form of tables and charts.
and in the recovery room. Modified Bromage
Scores at the beginning and at the end of surgery Results:
was noted. Fifteen minutes after the initiation of A total of 80 patients scheduled for transurethral
spinal anaesthesia, if the sensory block reaches to resection of prostate (TURP) under spinal
T10, permission was given to start the operation. anesthesia were randomly divided into two groups
If the sensory blockade is inadequate, general – Levobupivacaine (group I) and Bupivacaine
anaesthesia was induced. (heavy) (group II). It was observed which of the
two anesthetic agents provides better outcomes
A decrease in mean arterial pressure > 25% from
in terms of extent and duration of motor and
baseline level was defined as hypotension and was
sensory blockade and haemodynamic stability. The
treated with IV 5 mg ephedrine bolus. Heart rate
equal or less than 45 beats/min was defined as findings derived from the data analysis are
bradycardia and treated with IV 0.6 mg atropine presented below.

Table I: Comparison of baseline characteristics between groups

Baseline Characteristics Group I(n = 40) Group II (n = 40) p-value

Age (years)# 60.1 ± 6.4 60.7 ± 5.8 0.778
Weight (kg) # 65.6 ± 6.6 66.7 ± 6.4 0.961
ASA grade*
Grade I 5 (25%) 7 (35%) 0.659
Grade II 10 (50%) 10 (50%)
Grade III 5 (25%) 3 (15%)
Pulse (b/min)# 78.9 ± 8.2 88.1 ± 10.1 0.001ss
SBP (mmHg) # 130.8 1.6 137.3± 3.4 0.110
DBP (mmHg) # 79.3 ± 4.9 82.5 ± 7.3 0.109
Mean BP (mmHg)# 62.1 ± 5.0 64.1 ± 6.5 0.243
SpO2 (%)# 97.8 ± 0.89 98.7 ± 0.6 0.501
Figures in the parentheses indicate corresponding %; * Chi-squared Test (c2) was done to analyzed the data. # Data were
analyzed using Unpaired t-Test and were presented as mean ± SD.

Table I shows that the study subjects of both levopbupivacaine and bupivacaine groups were almost
similar in terms of age, weight and ASA grade (p = 0.778, p = 0.961 and p = 0.659). All the haemodynamic
variables (systolic, diastolic and mean blood pressures and oxygen saturation) except pulse were almost
homogeneously distributed between groups (p= 0.110, p = 0.109, p=0.243 and p = 0.501 respectively).
The pulse rate, although, was significantly lower in the former group than the latter group, they were
within normal physiological range.
118 Sir Salimullah Med Coll J Vol. 30, No. 2, July 2022

Table II: Comparison of heart rate at different time intervals between groups

Pulse# (beats/minute) Group I(n = 40) Group II(n = 40) P value

At baseline 77.9 8.2 88.1 ± 10.1 0.001
At 3 minutes 76.9 ± 7.9 88.3 ± 10.3 < 0.001
At 6 minutes 76.0 8.5 87.2 ± 10.9 0.001
At 9 minutes 74.4 ± 8.4 84.5 ± 10.9 0.002
At 12 minutes 73.6 9.1 83.7 ± 9.9 0.002
At 15 minutes 72.2 ± 8.3 82.7 ± 9.9 0.001
At 20 minutes 71.6 8.8 81.1± 9.8 0.003
At 25 minutes 71.8 ± 8.7 81.1 ± 8.8 0.002
At 30 minutes 72.6 7.9 80.7 ± 8.1 0.003
At 35 minutes 72.5 ± 7.1 80.2 ± 8.1 0.003
At 40 minutes 73.0 6.4 79.6 ± 7.9 0.006
At the end of surgery 73.9 ± 6.6 80.4 ± 7.2 0.005
# Data were analysed using Student’s t-Test and were presented as mean ± SD.

Fig. 1 depicts the changes in SBP at different time

The heart rate of the levobupivacaine group was
interval following intervention. The differences in
somewhat lower than that of bupivacaine group at
systolic blood pressures between two groups at any
entry, although both were within normal range.
point of observation were not significant (p > 0.05).
This difference was maintained up to the end of
Fig.2 showed that mean diastolic blood pressures at
surgery (Table II). However, there was no
baseline and at 3 minutes interval were somewhat
significant difference between the groups in terms
lower in the levobupivacaine group than those in
of changes in heart rate that occurred from baseline
the bupivacaine group, although the differences were
to endpoint of the study.
not statistically significant (p > 0.05).

140 100
130 90
120
80
110
Mean Diastolic BP (mm Hg)

100 70
Mean systolic BP (mm Hg)

90 60
80
50
70
60 40
50
30
40 GROUP
GROUP 20
30
20 Levobupivacaine
Levobupivacaine 10
10 0 Bupivacaine
0 Bupivacaine 0 3 6 9 12 15 20 25 30 35 40 End
0 3 6 9 12 15 20 25 30 35 40 End
Time interval (min)
Ttime interval (minute)

Fig.-1: Monitoring of SBP at different time interval Fig-2: Monitoring of DBP at different time interval
Outcome of Low-Dose 0.5% Levobupivacaine & Low-Dose 0.5% Bupivacaine Mohammad Ashrafur Rahman et al 119

Like diastolic blood pressures, the mean blood 100.0

pressures of levobupivacaine group at baseline and 99.0

at 3 minutes interval were somewhat lower than 98.0

those in the bupivacaine group, although the 97.0

differences were not statistically significant p >
96.0
0.05). At 6 minutes the mean blood pressure of

Mean SPO2 (%)

95.0
the two groups almost equalizes and dropped to
around 35 mmHg in either group at 12 minutes of 94.0

observation and no significant change was noted 93.0

thereafter at any level of evaluation up to the end 92.0
GROUP

of observation (Fig.3). Levobupivacaine

91.0
Oxygen saturation of the bupivacaine group was 90.0 Bupivacaine
0 3 6 9 12 15 20 25 30 35 40 End
significantly better (varied between 98.5 – 99%)
compared to that of levobupivacaine group which Time interval (min)

varied from 97.5 – 98%. The difference between Fig.-4: Monitoring of SpO2 at different time interval
the two groups at all levels of evaluation was
statistically significant (p < 0.05) (Fig. 4).
There was no significant difference between the
groups in terms of outcome variables (shown in
100
table III), except time to recovery from motor block.
90 The time to recovery from motor block was
80 significantly earlier in plain levobupivacaine group
70 than that in bupivacaine heavy group (p < 0.001).
60
Extension of sensory block up to T10 was achieved
Mean BP (mm Hg)

in 50% of the levobupivacaine and 30% of

50
bupivacaine groups.
40

30
At the beginning of surgery 60% of the
GROUP levobupivacaine group had Bromage score 1 while
20
70% of the bupivacaine group had Bromage score
10 Levobupivacaine
2. The difference between the two groups in terms
0 Bupivacaine
0 3 6 9 12 15 20 25 30 35 40 End
of Bromage score at the beginning of surgery was
significant (p = 0.007). At the end of surgery, 55%
Time interval (min)
of the former group and 20% latter group exhibited
Fig.-3. Monitoring of mean BP at different time interval a Bromage score of ‘0’ (p = 0.053) (Table IV).

Table III: Different sensory and motor block parameters between groups

Sensory and motor block parameters Group-I(n = 40) Group-II(n= 40) P value
Time to sensory block (min)# 10.2 ± 1.4 9.4 ± 1.8 0.099
Extension of sensory block*
T7 2(10%) 0(0.0 ) 0.086
T8 3(15%) 4(20%)
T9 5(25%) 10(50%)
T10 10(50%) 6(30%)
Time to motor block (min)# 4.3 ± 1.1 3.9 ± 1.0 0.167
Time to recovery from motor block (min)# 102.9 ± 9.1 118.2 ± 7.3 < 0.001SS
Time to segment regression# 63.2 ± 3.9 65.6 ± 3.9 0.074
Time to S2 regression# 113.4 ± 9.0 108.2 ± 14.7 0.190
Figures in the parentheses indicate corresponding %; *Chi-squared Test (c2) was done to analyzed the data.# Data were
analyzed using Unpaired t-Test and were presented as mean ± SD. ss=statistically significant.
120 Sir Salimullah Med Coll J Vol. 30, No. 2, July 2022

Tab IV: Bromage score at the beginning and end of surgery between groups
Bromage scores (0-3) Group I (n = 40) Group II (n = 40) P value
At the beginning of surgery*
1 12(60.0) 3(15.0) 0.007
2 8(40.0) 14(70.0)
3 0(0.0) 3(15.0)
At the end of surgery*
0 11(55.0) 4(20.0) 0.053
1 8(40.0) 12(60.0)
2 1(5.0) 4(20.0)

Figures in the parentheses indicate corresponding %; *Chi-squared Test (c2) was done to analyzed the data

Table V: Comparison of side effects between groups

Side-effects Group I (n = 40) Group II (n = 40) P value
Pruritus* 2(10.0) 7(35.0) 0.127
Total amount of ephedrine required (mg) 0.0 ± 0.0 5 ± 0.3 ——-
Figures in the parentheses indicate corresponding %; * Chi-squared Test (c2) was done to analyzed the data

Pruritus was the only side-effect encountered. The more or less stable hemodynamic profile for TURP
incidence of pruritus was considerably higher in surgery. For TURP surgery a sensory block
the bupivacaine group than that in the extending to T10 dermatome is necessary to
levobupivacaine group (p = 0.127). provide adequate analgesia, since monitoring
intravesical pressure is not available always9. The
While none of the levobupivacaine group required
recovery from motor block was also on an average
any ephedrine, 2 patients in the bupivacaine
17 minutes earlier in the levobupivacaine group
required it. The mean requirement of ephedrine
compared to the bupivacaine group. Over half (55%)
in the bupivacaine group was 5 mg (Table V).
of the former group exhibited complete recovery
Discussion: at the end of surgery as opposed to only 20% of the
In the present study demographic characteristics latter group.
(age and weight) and ASA grade were almost Consistent with the findings of the present study
identically distributed between the two study several studies showed Levobupivacaine and
groups. All the haemodynamic variables except
bupivacaine to be equally effective, in spinal and
heart rate were almost statistically matched. Half
epidural anaesthesia7.10.11..12. Levobupivacaine
of the levobupivacaine group achieved a sensory
was shown to have sensory-motor dissociation in
block up to the level of T10 which in the bupivacaine
group was achieved in 30% of the patients. The epidural13 and probably in spinal route14. Lee et
modified Bromage score ‘1’ at the beginning of the al15 (2005) firstly evaluated the effectiveness of 2.6
surgery was observed in 60% of the mL of 0.5% levobupivacaine in spinal route in
levobupivacaine and in 15% of the bupivacaine urological surgery and found that, onset time,
group. None of the levobupivacaine and 15% of degree of sensory and motor block and
the bupivacaine groups had a Bromage score ’3’. hemodynamic changes were similar to those for
Thus the findings of the present study demonstrate 2.6 ml 0.5% racemic bupivacaine. Vanna and
that 5 mg of 0.5% levobupivacaine with 25 mg associates16 showed that both isobaric solution of
fentanyl usage in spinal anaesthesia can provide levobupivacaine and hyperbaric solution of racemic
an adequate sensorial blockade without adequate bupivacaine in spinal anesthesia were similar in
motor block (low modified Bromage score) and terms of time to block suitable for surgery, duration
Outcome of Low-Dose 0.5% Levobupivacaine & Low-Dose 0.5% Bupivacaine Mohammad Ashrafur Rahman et al 121

of sensory block, time to two segments regression, depression or transient hypoxia was observed in
time to T12 regression, time to onset and offset of either group in the present study. However,
motor block, verbal numeric pain scores at the sharply contrasting with other studies that
start of the operation and adverse events. bupivacaine used in low doses3.17.19 do not produce
hypotensive period, the present study showed a
By using small doses of local anaesthetics, one can
sharp fall of diastolic and mean blood pressures at
limit the distribution of spinal block. But low doses
12 minutes of observation and 2 patients in the
of local anaesthetics could not provide an adequate
bupivacaine group needed treatment with
duration of sensory block3.. Adjuvant agents like
ephidrine.
opioids can, therefore, be used to enhance
analgesia and successful spinal anaesthesia. Levobupivacaine is increasingly popular in
Fentanyl has been widely used as an adjunct to replacing bupivacaine because of its equipotency
local anaesthetics for enhancement of analgesia with lower cardiovascular and central nervous
without intensifying motor and sympathetic block system side effects. It has very similar
in spinal anaesthesia17.18. pharmacokinetic properties to those of racemic
bupivacaine, several studies supported the notion
In previous studies3.4.19 dose sparing effect and
that its faster protein binding rate reflects a
augmentation block of bupivacaine with intrathecal
decreased degree of toxicity. The lethal dose for
fentanyl usage were confirmed in urological
levobupivacaine was significantly smaller than for
surgery. By this combination of bupivacaine and
bupivacaine.
fentanyl, dose reduction of bupivacaine can be
provided and this will cause less sympathetic Conclusion:
blockade, also resulting in lower incidence of From the findings of the study it can be concluded
hypotension, early recovery and mobilization. that, for TURP surgery that requires a sensory
Since the data regarding the usage of low dose block to at least T10 dermatome, a low dose of 5
levobupivacaine in spinal anaesthesia for urological mg levobupivacaine with 25 mg fentanyl can provide
surgery are limited, we tried to compare the adequate sensorial blockade without adequate
effectiveness of the low doses of levobupivacaine motor block and maintains a more or less stable
and bupivacaine when they are combined with hemodynamic profile. These findings suggest the
fentanyl, which have already been shown to be usage of low dose of levobupivacaine with fentanyl
effective in spinal anaesthesia for TURP surgery as a good alternative to bupivacaine in spinal
when used in higher doses. By using 5 mg anaesthesia for TURP surgery.However, as the
levobupivacaine + 25 mg fentanyl, an effective present study was conducted in a single center,
sensorial blockade was provided with less motor multicenter study with a further larger sample is
blockade than usage of 5 mg bupivacaine + 25 mg recommended to put forward a general
fentanyl. Vercauteren et al20 reported that, slight recommendation.
motor impairment seems to occur more often with
the use of racemic bupivacaine and they suggested Funding: No funding sources
to perform further studies to confirm that Conflict of interest: None declared
levobupivacaine causes less or short lasting motor
Ethical approval: The study was approved by
impairment. The present finding about less motor
the Institutional Ethics Committee of SSMC.
block in levobupivacaine group is going in favour
of this study. References:
1. Morgan GE, Mikhail MS & Murray MJ, ‘Inhalatinal
The present study did not show any significant side-
anaesthtics’, Clinical Anaesthesiology, 4th ed. Larson
effects in either group except pruritus (10% in the CP, Jr. Lange Medical Books, Mcgraw Hill, London,
levobupivacaine group and 35% in the bupivacaine 2006, pp. 169.
group). Pruritis is the common adverse effect of 2. Wadud MMA 2008, ‘Sevoflurane versus halothane for
intrathecal fentanyl usage which was also reported general anaesthersia in paedediatric patients-a
by other investigators21.22. As known, spinal comparative study of induction, haemodynamic
opioids carry the risk of respiratory depression resoponse and emergence’, MD thesis, Bangabandhu
Sheikh Mujib Medical University, pp. 45.
especially in elderly patients23, no respiratory
122 Sir Salimullah Med Coll J Vol. 30, No. 2, July 2022

3. Kararmaz A, Kaya S, Turhanoglu S, Ozyýlmaz MA 2003, 14. Camorcia M, Capogna G, Berritta C and Columb MO
‘Low dose bupivacaine-fentanyl spinal anaesthesia for 2007, ‘The relative potencies for motor block after
transurethral prostatectomy’, Anaesthesia, vol. 58, no. intrathecal ropivacaine, levobupivacaine, and
6, pp. 526-30. bupivacaine’, Anesthesia and Analgesia, vol. 104, no. 4,
4. Kuusniemi KS, Pihlajamaki KK, Pitkanen MT, pp. 904–07.
Helenius HY, Kirvela OA 2000, ‘The use of bupivacaine 15. Lee YY, Muchhal K, Chan CK, Cheung AS 2005,
and fentanyl for spinal anaesthesia for urological ‘Levobupivacaine and fentanyl for spinal anesthesia: a
surgery’, Anesth Analg, vol. 91, no. 6, pp. 1452-6.
randomized trial’, Eur J Anaesthesiol, vol. 22, pp. 899-
5. Mcleod GA, Burke D: 2001, Levobupivacaine. J 903.
Anaesthesia; vol 56 no. 4, pp. 331-41.
16. Vanna O, Chumsang L, Thongmee S 2006,
6. Casati A, Moizo E, Marchetti C, Vinciguerra F 2004, ‘A ‘Levobupivacaine and Bupivacaine in Spinal Anesthesia
prospective, randomized, double-blind comparison of for Transurethral Endoscopic Surgery’, J Med Assoc
unilateral spinal anesthesia with hyperbaric bupivacaine, Thai, vol. 89, no. 8, pp. 1133-9.
ropivacaine, or levobupivacaine for inguinal
herniorrhaphy’, Anesthesia and Analgesia, vol. 99, no. 17. Ben-David B, Frankel R, Arzumonov T, Marchevsky Y,
5, pp. 1387–92. Volpin G 2000, ‘Minidose bupivacaine-fentanyl spinal
anaesthesia for surgical repair of hip fracture in aged’,
7. Lee YY, Mucchal K, Chan CK 2003, ‘Levobupivacaine
Anesthesiology, vol. 92, no. 1, pp. 6-10.
versus racemic bupivacaine in spinal anaesthesia for
urological surgery’, Anaesth Intens Care, vol. 31, no. 6, 18. Ben-David B, Solomon E, Levin H, Admoni H, Goldik Z
pp. 637-41. 1997, ‘Intrathecal fentanyl with small dose dilute
8. Akcaboy EY, Akcaboy ZN, Nermin G 2011, ‘Low dose bupivacaine: better anaesthesia without prolonging
levobupivacaýne 0.5% with fentanyl in spinal recovery’, Anesth Analg, vol. 85, no. 3, pp. 560-5.
anaesthesia for transurethral resection of prostate 19. Goel S, Bhardwaj N, Grover VK 2003, ‘Intrathecal
surgery’, JRMS, vol. 16, no. 1, pp. 68-73. fentanyl added to intrathecal bupivacaine for day case
9. Malhotra V, Diwan S, ‘Anesthesia for the renal and surgery: a randomized study’, Eur J Anaesthesiol, vol.
genitourinary systems. In: Miller RD (Ed) Anesthesia’, 20, no. 4, pp. 294-7.
5th ed.Philadelphia: Churchill Livingstone; 2000. p. 20. Vercauteren MP, Hans G, De Decker K, Adriansen HA
1949.
2001, ‘Levobupivacaine combined with sufentanil and
10. Kopacz DJ, Allen HW, Thompson GE 2000, ‘A epinephrine for intrathecal labor analgesia: a
comparison of epidural levobupivacaine 0.75% with comparison with racemic bupivacaine’, Anesth Analg,
racemic bupivacaine for lower abdominal surgery’, vol. 93, no. 4, pp. 996-1000.
Anesth Analg, vol. 90, no. 3, pp. 642-8.
21. Liu S, Chiu AA, Carpenter RL, Mulroy MF, Allen HW,
11. Alley EA, Kopacz DJ, McDonald SB, Liu SS 2002, Neal JM, et al 1995, ‘Fentanyl prolongs lidocaine spinal
‘Hyperbaric spinal levobupivacaine: a comparison to
anaesthesia without prolonging recovery’, Anesth
racemic bupivacaine in volunteers’, Anesth Analg, vol.
Analg, vol. 80, no. 4, pp. 730-4.
94, no. 1, pp. 188-93.
22. Hamber EA, Viscomi CM 1999, ‘Intrathecal lipophilic
12. Glaser C, Marhofer P, Zimpfer G, Heinz MT, Sitzwohl
opioids as adjuncts to surgical spinal anaesthesia’, Reg
C, Kapral S, et al 2002, ‘Levobupivacaine versus racemic
Anesth Pain Med, vol. 24, no. 3, pp. 255-63.
bupivacaine for spinal anesthesia’, Anesth Analg, vol.
94, pp. 194-8 23. Fernandez-Galinski D, Rue M, Moral V, Castels C, Puig
13. Lacassie HJ, Columb MO 2003, ‘The relative motor MM 1996, ‘Spinal anaesthesia with bupivacaine and
blocking potencies of bupivacaine and levobupivacaine fentanyl in geriatric patients’, Anesth Analg, vol. 83,
in labour’, Anesth Analg, vol. 97, no. 5, pp. 1509-13. no. 3, pp. 537-41.