European Journal of Cardiovascular Medicine

Pain, as defined by the International Association for the Study of Pain, is “an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage” [1]. Effective management of pain remains a critical component of clinical care, especially in perioperative and interventional settings, as inadequate pain control can lead to prolonged recovery, patient dissatisfaction, and chronic pain syndromes [2]. Local and regional anesthesia techniques, which reduce the need for systemic analgesics, have gained popularity due to their ability to provide targeted pain relief with fewer systemic side effects [3].

Among the anesthetic agents used for local or regional blocks, lidocaine, bupivacaine, and ropivacaine are among the most frequently administered. Each of these agents possesses distinct pharmacokinetic and pharmacodynamic profiles, making their selection highly dependent on the clinical scenario [4]. Lidocaine, a short-acting amide local anesthetic, is appreciated for its rapid onset of action and is often favored for minor procedures [5]. Bupivacaine, with a longer duration of action, is commonly used in surgeries requiring prolonged analgesia; however, its potential for cardiotoxicity at higher doses raises concerns [6]. Ropivacaine, a newer amide-type anesthetic, was developed to address some of the safety concerns associated with bupivacaine. It exhibits a favorable profile with reduced central nervous system and cardiac toxicity, while maintaining sufficient duration and intensity of analgesia [7].

Pain management is not only about analgesia but also about improving patient outcomes, including functional recovery, quality of life, and satisfaction with care. Therefore, evaluating anesthetic agents solely based on onset and duration of action is insufficient. Parameters such as incidence of side effects, patient-reported outcome measures (PROMs), and overall satisfaction must be included to provide a more holistic view [8]. While there are multiple studies evaluating individual anesthetics, comparative studies that assess these agents under standardized conditions with respect to multiple outcomes are limited in scope [9].

This study was designed to compare the effectiveness of lidocaine, bupivacaine, and ropivacaine in terms of onset time, duration of analgesia, side effect profile, and patient satisfaction in a real-world pain management setting. By using a randomized design and including commonly used outcome measures, we aim to inform clinicians on the relative merits and limitations of each agent, facilitating more personalized anesthetic planning [10].

Furthermore, as the healthcare system continues to evolve toward patient-centered care, understanding how anesthetic choice influences subjective experiences and clinical endpoints becomes essential. This study provides an evidence-based approach to guide anesthetic selection for various interventional and perioperative scenarios.

Study Design and Setting

This was a prospective, randomized, comparative clinical trial conducted over a period of 6 months at a tertiary care center in India. The study aimed to compare three commonly used local anesthetic agents—lidocaine, bupivacaine, and ropivacaine—in patients undergoing pain management therapy, including nerve blocks and minor surgical procedures.

Ethical Considerations

Prior ethical clearance was obtained from the Institutional Ethics Committee. Written informed consent was obtained from all participants prior to enrollment, in accordance with the Declaration of Helsinki.

Sample Size Calculation

A minimum sample size of 90 patients (30 in each group) was calculated based on a power of 80%, alpha error of 0.05, and anticipated intergroup difference in mean duration of analgesia of 1.5 hours with a standard deviation of 2.1 hours.

Participants

A total of 90 adult patients aged between 18 and 65 years, classified as ASA (American Society of Anesthesiologists) physical status I or II, were enrolled.

Inclusion Criteria:

• Patients scheduled for minor surgical or diagnostic procedures requiring regional or local anesthesia
• Willing to provide written informed consent
• Normal renal and hepatic function

Exclusion Criteria:

• Known hypersensitivity to local anesthetics
• Pregnant or lactating women
• Neurological disorders or chronic pain syndromes
• History of substance abuse or psychiatric illness
• Coagulopathy or local infection at injection site

Randomization and Group Allocation

Patients were randomized into three groups (n=30 each) using a computer-generated random number table:

• Group A: Received 2% Lidocaine
• Group B: Received 0.5% Bupivacaine
• Group C: Received 0.75% Ropivacaine

All drugs were administered in equivalent volumes (20 mL), using standard sterile technique under ultrasound guidance where appropriate.

Outcome Parameters

Primary and secondary outcome measures were evaluated by a blinded investigator.

Blinding

The anesthetist administering the drug was not involved in the outcome assessment. Both the patients and the observer recording the results were blinded to group allocation.

  Statistical Analysis

Data were entered into SPSS Version 26.0. Continuous variables (onset time, duration) were expressed as mean ± SD and analyzed using one-way ANOVA with post hoc Tukey test. Categorical variables (adverse events, satisfaction) were compared using the Chi-square test. A p-value <0.05 was considered statistically significant.

A total of 90 patients were included in the study, with 30 patients in each group receiving lidocaine (Group A), bupivacaine (Group B), or ropivacaine (Group C). Baseline demographic and clinical characteristics were comparable across all groups, indicating appropriate randomization.

Table 1: Demographic Characteristics

There were no statistically significant differences in age, gender distribution, body mass index (BMI), or ASA status among the three groups (p > 0.05), ensuring comparability.

Table 1: Baseline Demographics of Study Participants

Table 2: Onset of Action

Group A (lidocaine) demonstrated the fastest onset of sensory block (2.2 ± 0.4 minutes), followed by ropivacaine and bupivacaine. The difference was statistically significant (p < 0.01).

Table 2: Onset of Sensory Block (in minutes)

Table 3: Duration of Analgesia

Group C (ropivacaine) had the longest duration of analgesia (7.3 ± 1.0 hours), significantly longer than both bupivacaine (6.4 ± 1.2 hours) and lidocaine (2.9 ± 0.6 hours), with p < 0.001.

Table 3: Duration of Analgesia (in hours)

Table 4: Adverse Effects and Patient Satisfaction

Lidocaine group had more systemic side effects (20% reported nausea, dizziness), while bupivacaine and ropivacaine had lower adverse events. Patient satisfaction was highest with ropivacaine (Likert score 4.6 ± 0.5), followed by bupivacaine and lidocaine.

Table 4: Adverse Events and Satisfaction Score

This comparative study evaluated the clinical efficacy and safety of three commonly used local anesthetic agents—lidocaine, bupivacaine, and ropivacaine—by analyzing their onset time, duration of analgesia, adverse effects, and patient satisfaction. The findings highlight important pharmacological and clinical differences among these agents, which have significant implications for personalized anesthetic planning in pain management.

In our study, lidocaine demonstrated the fastest onset of sensory block (mean 2.2 minutes), aligning with established literature describing its rapid diffusion across nerve membranes and high lipid solubility [6]. Lidocaine’s quick onset makes it suitable for short-duration or outpatient procedures where speed is prioritized over longevity of action. However, its relatively short duration of analgesia (2.9 hours), as observed here, limits its application for prolonged postoperative pain relief. Similar results were reported by previous studies that noted lidocaine’s duration to be approximately 2–3 hours in peripheral nerve blocks [7].

Bupivacaine, in contrast, had a significantly longer duration of action (6.4 hours) but a slower onset time (3.1 minutes). This profile is well-suited for intermediate-duration procedures where prolonged analgesia is desired without the need for continuous infusion. However, its known cardiotoxic potential has long been a limitation, especially when used in high doses or inadvertent intravascular injections occur [8]. Although our study did not record any cardiotoxic events, two patients in the bupivacaine group reported mild dizziness, supporting previous concerns about systemic effects even at therapeutic doses [9].

Ropivacaine emerged as the most favorable agent overall, with the longest duration of analgesia (7.3 hours), relatively quick onset (2.8 minutes), and lowest incidence of side effects (3.3%). Importantly, patient satisfaction was highest in this group (4.6/5 Likert score). These results corroborate with the previous findings that showed that ropivacaine provides effective nerve blockade with a reduced risk of central nervous system and cardiac toxicity due to its reduced lipophilicity and lower potency on sodium channels in cardiac tissue [10]. Moreover, its differential blockade—preferentially blocking sensory rather than motor fibers—has made it particularly useful in ambulatory and postoperative settings [11].

The difference in adverse event profiles between the three drugs further substantiates the superior safety margin of ropivacaine. Six patients in the lidocaine group reported systemic effects such as nausea and dizziness, which may be attributed to faster systemic absorption and higher peak plasma concentrations [12]. Bupivacaine had intermediate safety, while ropivacaine was associated with minimal complications. This gradient of toxicity and duration is consistent with previous findings that observed a better balance of efficacy and safety with ropivacaine in various surgical procedures [13].

From a patient-centric standpoint, the satisfaction score serves as a composite marker for comfort, efficacy, and side-effect profile. The significantly higher satisfaction score in the ropivacaine group suggests that its pharmacological benefits translate meaningfully into improved patient experience, a critical parameter in the era of value-based care [14].

Despite these findings, our study is not without limitations. It was a single-center trial with a relatively small sample size, which may limit generalizability. The study was limited to short-term outcomes (24-hour window), so the incidence of delayed complications or rebound pain was not assessed. Additionally, cost analysis was beyond the scope of this study, although ropivacaine is typically more expensive than lidocaine and bupivacaine, which may influence selection in resource-constrained settings [15].

Future studies should explore combinatorial anesthetic strategies, patient-specific factors such as age and comorbidities, and integration of nerve-sparing techniques to further optimize anesthetic protocols. A multi-centric trial with larger cohorts and longer follow-up is recommended to substantiate and refine the clinical utility of ropivacaine as a first-line agent in pain management protocols.

This study concludes that ropivacaine offers the most balanced profile among the three anesthetic agents studied, with prolonged analgesia, minimal side effects, and highest patient satisfaction. Lidocaine, while having a rapid onset, is limited by its short duration and higher rate of systemic symptoms. Bupivacaine remains a reliable intermediate agent but warrants caution due to its toxicity potential. Tailoring anesthetic choice based on procedural duration, patient profile, and safety requirements is essential for effective pain management. These results support the preferential use of ropivacaine in scenarios where extended analgesia and patient comfort are priorities.

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