In an interview with MIMS Doctor, Dr Wing-Sang Chan, Specialist in Anaesthesiology at the Chinese University of Hong Kong (CUHK) Medical Centre, shared clinical insights on use of ropivacaine across a number of surgical procedures, including its application in transversus abdominis plane (TAP) block, and explained how a local anaesthetic’s (LA) safety profile may determine its utility in clinical practice.
Why use TAP block?
TAP block is a type of regional anaesthesia (RA) with proven efficacy across a variety of abdominal surgeries, such as caesarean section, hysterectomy, cholecystectomy, colectomy, prostatectomy, and hernia repair. [Biomed Res Int 2017;2017:8284363]
“RA, including TAP block, has a lot of advantages over general anaesthesia [GA],” said Chan. “It can improve patients’ experience by reducing immediate postoperative pain and risk of early complications, such as postoperative nausea, respiratory problems, and thromboembolism. It also enhances gastrointestinal recovery and early mobilization. In addition, RA minimizes the risk of long-term complications, such as chronic postsurgery pain.” [Periodicum Biologorum 2009;111:203-208; BMC Anesthesiol 2024;24:87; BJA Educ 2024;24:46-56; Ann R Coll Surg Engl 2014;96:579-585; Anesth Pain Med 2023;13:e134864; Pain Med 2020;21:378-386]
Randomized, controlled clinical trials in adults undergoing general abdominal surgery, caesarean delivery, or total hysterectomy have shown that TAP block provides highly effective analgesia in the first 24–48 hours postsurgery, reducing mean IV morphine consumption by >70 percent vs older standards of care, such as patient-controlled morphine analgesia (PCMA) and regular NSAIDs and acetaminophen. [Anesth Analg 2007;104:193-197; Anesth Analg 2008;106:186-191; Anesth Analg 2008;107:2056-2060]. This, in turn, results in fewer opioid-mediated side effects, including significantly reduced postoperative nausea. [BMC Anesthesiol 2024;24:87]
Due to its relatively low risk of complications and ease of performance, TAP block is widely used for providing postoperative analgesia. [Acta Anaesthesiol Taiwan 2014;52:49-53] “If patients feel good immediately after surgery, it enhances their overall experience of medical care, reassures their family and allows them to return home sooner, thereby reducing the overall burden to individual patients, societal cost and use of healthcare resources,” noted Chan.
Extended pain relief with ropivacaine
Ropivacaine is a long-acting regional anaesthetic that is structurally similar to bupivacaine. However, unlike the racemic mixture of bupivacaine, ropivacaine is manufactured as a pure S(-) enantiomer, a feature that reduces its toxicity and improves its sensory and motor block profiles. [Cureus 2024;16:e67565]
Ropivacaine’s efficacy at reducing postoperative pain has been established in clinical trials across various therapeutic areas. The addition of a TAP block with 0.5 percent ropivacaine to standard GA in a double-blind clinical trial of 200 women undergoing laparoscopic gynaecologic surgery was associated with lower mean pain scores vs standard GA alone between 30 minutes and 48 hours after surgery (p<0.001). [Adv Biomed Res 2022;11:12] Adding a TAP block with 0.2 percent ropivacaine on either side of the abdominal wall lowered visual analog scale (VAS) pain scores at rest and when coughing (p<0.001 for both) and extended the time to first request of analgesia (p<0.001) in a prospective, randomized, double-blind, placebo-controlled trial in 80 patients undergoing colorectal surgery. (Table 1)[Anesth Essays Res 2017;11:767772]
In a trial assessing the efficacy of 0.375 percent ropivacaine vs 0.25 percent bupivacaine in ultrasound-guided TAP block administered to 60 adults undergoing elective laparoscopic cholecystectomy, ropivacaine was associated with significantly lower pain scores at 10 minutes (p=0.044), 30 minutes (p=0.003) and 1 hour (p=0.020). [Indian J Anaesth 2016;60:264-269] In renal transplantation, TAP block with 0.33 percent ropivacaine administered under ultrasound guidance reduced morphine consumption during the first 24 hours after surgery and extended the average time to first request for morphine, as well as reduced VAS scores at 2 and 4 hours postsurgery vs PCMA. [Int J Surg 2020;79:196-201]
In addition, a recent systematic review and meta-analysis found that ropivacaine is suitable for intraperitoneal instillation, where its use significantly reduces total opioid consumption after digestive surgery, improves acute pain management across different procedures, enhances postoperative recovery by reducing nausea and vomiting, shortens hospital stays, and lowers shoulder pain frequency, making it a valuable component of the Enhanced Recovery After Surgery protocol. [Medicine (Baltimore) 2024;103:e38856]
Safety profile defines utility
Ropivacaine provides prolonged postoperative analgesia with a greater margin of central nervous system (CNS) and cardiac safety. [Expert Rev Neurother 2004;4:781-791; Acta Anaesthesiol Taiwan 2014;52:49-53]
“Prolonged postoperative pain relief is all-important in major surgeries, especially those affecting patients’ mobility and respiratory function, such as orthopaedic and abdominal surgeries as well as thoracotomies, where effective pain control encourages earlier mobility and thus improves pulmonary functioning,” explained Chan. “While all RA agents provide analgesia and minimize use of opioids, ropivacaine is particularly advantageous due to its prolonged action, minimal cardiotoxicity and lowest degree of motor blockade. Due to its lower toxicity, ropivacaine can be administered in higher doses to ensure prolonged pain relief without compromising safety.” [Indian J Anaesth 2011;55:104-110]
Considering motor blockade, chondro-and cardiotoxicity in orthopaedic patients
Early mobilization following orthopaedic surgeries, such as total hip and knee arthroplasty, is associated with shorter hospital stay, which improves functional recovery and facilitates a more rapid return to independent living. [Disabil Rehabil 2023;45:4252-4258; Arch Physiother 2020;10:8; Ann Transl Med 2019;7:69] “Therefore, a LA that can offer prolonged pain relief with minimal motor blockade would be optimal,” said Chan.
Ropivacaine is less lipophilic than other LAs, and therefore less likely to penetrate large myelinated motor fibres. This explains why it produces a less potent motor blockade than bupivacaine or levobupivacaine. (Table 2) [Anesth Analg 2007;104:904-907] A study of 503 patients undergoing total hip arthroplasty with spinal anaesthesia showed that ropivacaine was associated with superior ambulation time and distance and quicker post-anaesthesia care unit transition vs bupivacaine. [Orthopedics 2021;44:e343-e346]
Intra‐articular joint injections of LAs relieve symptoms and aid diagnosis of degenerative joint disease. However, in vitro and in vivo evidence suggests that some LA agents have considerable chondrocyte and synoviocyte toxicity. [Knee Surg Sports Traumatol Arthrosc 2018;26:819- 830; Cartilage 2015;6:233-240] For instance, quantitative histological analysis of rat knees given a single 0.5 percent bupivacaine injection revealed an up to 50 percent reduction in chondrocyte density vs saline-solution–treated knees at 6 months postinjection (p≤0.01). [J Bone Joint Surg Am 2010;92:599-608] “A single dose of some anaesthetics, like lignocaine, can kill human chondrocytes, especially in cases with poor joint condition,” warned Chan. “Ropivacaine seems to be the LA that is least toxic to human chondrocytes.” [Cartilage 2018;10:364-369]
A systematic review and meta-analysis of eight randomized clinical trials showed that a single intra-articular injection of ropivacaine administered at the end of arthroscopic knee surgery provides effective pain relief in the immediate and early postoperative periods without increasing short-term side effects. [Knee Surg Sports Traumatol Arthrosc 2016;24:1651-1659] Another systematic review found evidence of chondrotoxicity in five out of seven studies evaluating lidocaine and 13 out of 14 studies examining bupivacaine, while ropivacaine at concentrations <0.5 percent was found to be less chondrotoxic than lidocaine, bupivacaine, levobupivacaine, and mepivacaine. [PMR 2019;11:379-400]
“Cardiotoxicity is another concern [with orthopaedic procedures],” mentioned Chan. “In case of pericapsular injections, higher volume and dose of LA are required, which can be done with ropivacaine because of its low cardiotoxicity.” Compared with bupivacaine, ropivacaine has a shorter elimination half-life and therefore less potential to accumulate. Ropivacaine also offers an increased margin of safety vs bupivacaine when given in equal doses as it produces less direct myocardial depression. Furthermore, according to animal studies, margin of safety for arrhythmogenesis is greater for ropivacaine than bupivacaine or levobupivacaine, and ropivacaine has a greater success rate of cardiac resuscitation than the other two agents. [Anesthesiology 2002;96:1427-1434]
Due to its favourable CNS and cardiac safety, ropivacaine is also the most widely used LA for brachial plexus block (BPB), which is given to patients undergoing upper limb surgery. [Front Pharmacol 2023;14:1288697] A recent systematic review and meta-analysis found that compared with ropivacaine, levobupivacaine produces a significantly longer sensory and motor block in patients undergoing BPB, making ropivacaine the preferred option if a quick return of motor function is desired. [Indian J Anaesth 2025;29;69:179-190]
Optimal safety profile for childbirth
“Because of its relative cardiac and CNS safety and minimal motor blockade, ropivacaine is a good agent for pain relief in childbirth,” said Chan. “Epidural anaesthesia affects mobility, and vaginal delivery is difficult with weak lower limbs. Having less motor blockade helps the mother.”
A study of 615 maternal patients compared use of ropivacaine vs levobupivacaine for combined spinal-epidural anaesthesia during childbirth. Compared with levobupivacaine, ropivacaine had a faster onset of action and less impact on maternal vital signs, and was associated with a reduced rate of conversion to caesarean section. No significant difference in 1- and 5-minute Apgar scores was reported between the two groups. [Exp Ther Med 2019;18:2307-2313]
In women undergoing caesarean section under epidural anaesthesia with 0.5 or 0.75 percent ropivacaine or 0.25 percent epidural ropivacaine for labour, no adverse maternal or foetal events were reported. In three studies comparing ropivacaine and bupivacaine for epidural anaesthesia, Neurological and Adaptive Capacity Scores were better with ropivacaine during the first 24 hours. [Expert Rev Neurother 2004;4:781-791]
Conclusion
Ropivacaine provides extended postoperative analgesia with relatively low CNS, cardiac and chondrocyte toxicity and minimal motor blockade, making it suitable for a wide range of surgeries requiring RA, including abdominal laparoscopy, caesarean section, vaginal delivery, and lower and upper limb orthopaedic surgery.
