Enantiomeric Local Anesthetics: Can Ropivacaine and Levobupivacaine Improve Our Practice?

The novel, long-acting local anesthetics (LAs) ropivacaine and levobupivacaine were developed to offer a safer alternative to bupivacaine. The well-known toxic effects of bupivacaine on the central nervous system and the cardiovascular system seem to be less severe when comparable plasma levels of these pure levorotatory agents are reached. Although there is evidence of greater safety in the experimental setting, its actual impact on clinical practice remains unclear. Randomized, controlled trials using clinical endpoints have shown that the enantiomeric LAs are viable alternatives to bupivacaine, and may offer advantages in some settings where a greater differentiation between motor and sensory block may become evident. The available evidence seems to support the use of the novel LAs over bupivacaine whenever large doses are used or the risk of unintended intravascular injection is high, such as in continuous epidural analgesia or peripheral nerve blocks.