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The toxicity of local anesthetics: the place of ropivacaine and levobupivacaine

Zink, Wolfgang; Graf, Bernhard M

Current Opinion in Anesthesiology: October 2008 - Volume 21 - Issue 5 - p 645–650
doi: 10.1097/ACO.0b013e32830c214c
Regional anesthesia: Edited by Bernadette Veering

Purpose of review Ropivacaine and levobupivacaine were developed after evidence of bupivacaine-related severe toxicity. Despite a comparable analgesic profile, quantitative differences become evident with regard to their specific rate of systemic toxicity. The present article provides a concise review of the toxic potencies of levobupivacaine and ropivacaine.

Recent findings As lipophilicity is known to be a major determinant in local anesthetic toxicity, the clinical safety profile of ropivacaine seems to be more favorable than that of levobupivacaine. Experimental studies and case reports confirm this hypothesis, showing that ropivacaine is characterized by fewer (cardio) toxic effects and, most probably, a greater margin of safety. Both agents also may dose dependently damage neurons and skeletal muscle tissue at the injection site. Although their specific rate of neurotoxicity appears to be rather low, levobupivacaine is characterized by an outstanding myotoxic potential.

Summary Compared with bupivacaine, both agents may be considered as ‘more well tolerated’ but not as ‘totally well tolerated’, as they are still capable of inducing systemic and local toxicity. However, ropivacaine seems to have the greatest margin of safety of all long-acting local anesthetics at present.

Department of Anesthesiology, Emergency and Intensive Care Medicine, University of Goettingen, Goettingen, Germany

Correspondence to Bernhard M. Graf, MD, PhD, MSc, Department of Anesthesiology, Emergency and Intensive Care Medicine, University of Goettingen, Robert-Koch-St 40, 37075 Goettingen, Germany Tel: +49 551 39 6051; fax: +49 551 39 13886; e-mail:

© 2008 Lippincott Williams & Wilkins, Inc.