Medically reviewed on Feb 8, 2019
(roe PIV a kane)
- Ropivacaine Hydrochloride
Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product
Solution, Injection, as hydrochloride [preservative free]:
Naropin: 2 mg/mL (10 mL, 20 mL, 100 mL, 200 mL); 5 mg/mL (20 mL, 30 mL, 100 mL [DSC], 200 mL); 7.5 mg/mL (20 mL); 10 mg/mL (10 mL, 20 mL)
Generic: 2 mg/mL (10 mL, 20 mL, 100 mL, 200 mL); 5 mg/mL (20 mL, 30 mL); 7.5 mg/mL (20 mL); 10 mg/mL (10 mL, 20 mL)
Brand Names: U.S.
- Local Anesthetic
Blocks both the initiation and conduction of nerve impulses by decreasing the neuronal membrane's permeability to sodium ions, which results in inhibition of depolarization with resultant blockade of conduction
Children: Epidural infusion: 2.1 to 4.2 L/kg (Hansen 2000)
Adults: Intravascular infusion: 41 ± 7 L
Hepatic, via CYP1A2 to metabolites
Urine (86% as metabolites)
Onset of Action
Anesthesia (route dependent): 3 to 15 minutes
Time to Peak
Serum (dose and route dependent): Caudal:
Infants: Median: 60 minutes (range: 15 to 90 minutes) (Wulf 2000)
Children: Mean: 60 minutes (range: 12 to 249 minutes (Lonnqvist 2000)
Duration of Action
Dose and route dependent: 3 to 15 hours
Children: Epidural: Terminal phase:4.9 hours (range: 3 to 6.7 hours) (Hansen 2000)
Adults: Epidural: 5 to 7 hours; IV: Terminal: 111 ± 62 minutes (Lee 1989)
Use: Labeled Indications
Acute pain management: For acute pain management administered as an epidural continuous infusion, intermittent bolus (eg, postoperative or labor), or local infiltration.
Surgical anesthesia: For the production of local or regional anesthesia for surgery administered as an epidural block, including cesarean section, major nerve block, or local infiltration.
Hypersensitivity to ropivacaine, amide-type local anesthetics (eg, bupivacaine, mepivacaine, lidocaine), or any component of the formulation
Canadian labeling: Additional contraindications (not in US labeling): Intravenous regional anesthesia (Bier block); obstetric paracervical block anesthesia
Dose varies with procedure, onset and depth of anesthesia desired, vascularity of tissues, duration of anesthesia, and condition of patient: A test dose of short-acting local anesthestic containing epinephrine (eg, 3 to 5 mL) should be administered prior to induction of complete block with ropivacaine. Incremental ropivacaine dosing is recommended. Adults:
Lumbar epidural block for surgery:
15 to 30 mL of 0.5% solution
15 to 25 mL of 0.75% solution
15 to 20 mL of 1% solution
Lumbar epidural block for cesarean section:
20 to 30 mL dose of 0.5% solution
15 to 20 mL dose of 0.75% solution
Thoracic epidural block:
5 to 15 mL dose of 0.5% solution
5 to 15 mL dose of 0.75% solution
Major nerve block:
35 to 50 mL dose of 0.5% solution
10 to 40 mL dose of 0.75% solution
Field block: 1 to 40 mL dose of 0.5% solution
Labor pain management: Lumbar epidural: Initial: 10 to 20 mL 0.2% solution; continuous infusion dose: 6 to 14 mL/hour of 0.2% solution with incremental injections of 10 to 15 mL/hour of 0.2% solution
Postoperative pain management:
Peripheral nerve block: Continuous infusion dose: 5 to 10 mL/hour of 0.2% solution (Bagry, 2008; Klein, 2000)
Lumbar or thoracic epidural: Continuous infusion dose: 6 to 14 mL/hour of 0.2% solution
Infiltration/minor nerve block:
1 to 100 mL dose of 0.2% solution
1 to 40 mL dose of 0.5% solution
Refer to adult dosing. Use with caution; initial dose reductions may be necessary.
Note: Dose varies with procedure, depth of anesthesia, vascularity of tissues, duration of anesthesia, and condition of patient. Consider incremental administration with negative aspiration prior to each injection; however, absence of blood in the syringe does not guarantee that intravascular injection has been avoided (Mulroy 2010). Should only be administered under the supervision of a qualified physician experienced in the use of anesthetics. Dosing units variable (mL/kg, mg/kg); use extra precaution to ensure accuracy and minimize potential toxicity.
Central nerve blocks/anesthesia (eg, caudal, lumbar, thoracic): Limited data available:
Caudal block: Infants and Children: Caudal injection: 0.2% (2 mg/mL) solution: 0.5 to 1 mL/kg; some experts suggest a maximum volume of 25 mL (Ivani 1998; Ivani 2002; Jöhr 2015; Kokinsky 2003; Lonnqvist 2000)
Epidural block (eg, lumbar, thoracic): Infants, Children, and Adolescents: Epidural injection 0.2% (2 mg/mL): 0.7 mL/kg. Note: For infants (particularly young infants) if repeat injections necessary, a decreased dose may be necessary to prevent drug accumulation. Some experts suggest if at least 45 minutes since initial dose, reduce dose to 1/3 of the initial or if at least 90 minutes since initial dose, then reduce dose to half of the initial. If additional doses are necessary, doses should be reduced to half of the previous dose (Ivani 1999; Miller 2015).
Epidural, continuous infusion:
Infants <3 months: Epidural injection: Bolus: Usual concentration 0.2% (2 mg/mL) solution: Reported range: 0.5 to 1 mL/kg. In some cases, a more dilute solution (eg, 0.1% [1 mg/mL]) may be required to ensure adequate volume and minimize toxicity. Follow with continuous epidural infusion of 0.2% (2 mg/mL) solution at 0.2 mg/kg/hour (Bosenberg 2005; Hansen 2000; Miller 2015)
Infants ≥3 months, Children, and Adolescents: Epidural injection: 0.2% (2 mg/mL) solution: Bolus: Reported range: 0.5 to 1 mL/kg administered over several minutes (eg, 3 to 5 minutes) followed by continuous epidural infusion at 0.4 mg/kg/hour; in adults, usual rates are 6 to 14 mL/hour of 0.2% solution (Berde 2008; Bosenberg 2005; Hansen 2000)
Peripheral nerve blocks/ local anesthesia: Limited data available: Note: Dose varies with location of block (ie, procedure), depth of anesthesia, vascularity of tissues, duration of anesthesia, and patient parameters (eg, age, weight, condition).
Single injection: The volume of dose (mL/kg) and concentration of solution are site-specific based upon anatomy and variable among patients and procedure (Coté 2013; Miller 2015).
Infants ≥6 months, Children, and Adolescents: Suggested or reported dose volumes presented; not to exceed a suggested maximum dose of 3 mg/kg/dose based on lean body mass; dosing based on extrapolation from adult experience; additional data necessary to more clearly define pediatric upper dose limit. Note: For infants <6 months, dose reductions (eg, by 30%) have been suggested by experts (Coté 2013; Visoiu 2015).
Head and neck blocks: 0.05 mL/kg
Maxillary nerve: 0.15 mL/kg (Chiono 2014; Sola 2012)
Upper extremity blocks:
Brachial plexus: 0.2 to 0.3 mL/kg
Digital nerve: ≤0.2% (2 mg/mL) solution: 0.05 mL/kg
Transversus abdominis plane: 0.2 to 0.5 mL/kg (Jöhr 2015)
Ilioinguinal nerve: 0.075 mL/kg
Rectus sheath: 0.1 to 0.2 mL/kg
Lower extremity blocks:
Femoral nerve: 0.2% to 0.5% (2 to 5 mg/mL) solution: 0.2 to 0.4 mL/kg (Coté 2013; Schloss 2014; Veneziano 2016)
Sciatic nerve: 0.2 to 0.3 mL/kg
Continuous peripheral nerve block infusion (CPNB) (Dadure 2009; Duflo 2006; Iliev 2016; Visoiu 2014): Infants ≥6 months, Children, and Adolescents:
Initial bolus: 0.2% (2 mg/mL) solution: Dose dependent on nerve catheter location: Commonly reported dose range: ~0.5 to 1.32 mg/kg; some patients and/or catheter/nerve sites may require a higher bolus dose; a trial evaluating 403 pediatric catheter placements reported an overall median bolus for all catheter sites of 1.32 mg/kg (IQR: 0.82 to 1.95 mg/kg); another trial reporting on 339 pediatric catheter placements reported a mean initial bolus dose of 0.49 to 0.98 mg/kg.
Continuous peripheral nerve block infusion: 0.2% (2 mg/mL) solution: Reported mean rate range: 0.11 to 0.25 mg/kg/hour (most experience reported at 0.2 to 0.25 mg/kg/hour); reported IQR range from 403 pediatric catheter placements: 0.12 to 0.33 mg/kg/hour (depending upon catheter site) with a usual duration <72 hours; majority of experience is postoperative pain management following orthopedic procedures including administration via On-Q pump or Ambu Smart-Infuser
Spinal anesthesia: Limited data available: Infant, Children, and Adolescents ≤17 years: Intrathecal (via LP site; L 3-5): Preservative-free 0.5% (5 mg/mL) isobaric solution: 0.5 mg/kg; maximum dose: 20 mg/dose (Kokki 2005)
Administered via local infiltration, epidural block and epidural infusion, or intermittent bolus. Prior to ropivacaine administration, a test dose of short-acting local anesthestic with epinephrine (eg, 3 to 5 mL) should be administered. Incremental ropivacaine dosing is recommended. Do not administer large volume of anesthetic rapidly. The On-Q infusion pump is used to slowly administer local anesthetics (eg, bupivacaine, lidocaine, ropivacaine) to or around surgical wound sites and/or in close proximity to nerves for pre- or postoperative regional anesthesia. When infused directly into the shoulder, destruction of articular cartilage (chondrolysis) has occurred. On-Q pumps should never be placed directly into any joint (see https://www.ismp.org/Newsletters/acutecare/archives/May09.asp).
Store at 20°C to 25°C (68°F to 77°F). Infusions should be discarded after 24 hours.
Abiraterone Acetate: May increase the serum concentration of CYP1A2 Substrates (High risk with Inhibitors). Monitor therapy
Alfuzosin: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Monitor therapy
Amifostine: Blood Pressure Lowering Agents may enhance the hypotensive effect of Amifostine. Management: When amifostine is used at chemotherapy doses, blood pressure lowering medications should be withheld for 24 hours prior to amifostine administration. If blood pressure lowering therapy cannot be withheld, amifostine should not be administered. Consider therapy modification
Antipsychotic Agents (Second Generation [Atypical]): Blood Pressure Lowering Agents may enhance the hypotensive effect of Antipsychotic Agents (Second Generation [Atypical]). Monitor therapy
Barbiturates: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Monitor therapy
Benperidol: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Monitor therapy
Blood Pressure Lowering Agents: May enhance the hypotensive effect of Hypotension-Associated Agents. Monitor therapy
Brimonidine (Topical): May enhance the hypotensive effect of Blood Pressure Lowering Agents. Monitor therapy
Bromperidol: Blood Pressure Lowering Agents may enhance the hypotensive effect of Bromperidol. Bromperidol may diminish the hypotensive effect of Blood Pressure Lowering Agents. Avoid combination
Bupivacaine (Liposomal): Local Anesthetics may enhance the adverse/toxic effect of Bupivacaine (Liposomal). Management: Liposomal bupivacaine should not be administered with local anesthetics. Liposomal bupivacaine may be administered 20 minutes or more after the administration of lidocaine, but the optimal duration of dose separation for other local anesthetics is unknown Avoid combination
Ciprofloxacin (Systemic): May increase the serum concentration of Ropivacaine. Monitor therapy
CYP1A2 Inhibitors (Moderate): May decrease the metabolism of CYP1A2 Substrates (High risk with Inhibitors). Monitor therapy
Deferasirox: May increase the serum concentration of CYP1A2 Substrates (High risk with Inhibitors). Monitor therapy
Diazoxide: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Monitor therapy
DULoxetine: Blood Pressure Lowering Agents may enhance the hypotensive effect of DULoxetine. Monitor therapy
FluvoxaMINE: May increase the serum concentration of Ropivacaine. Monitor therapy
Herbs (Hypotensive Properties): May enhance the hypotensive effect of Blood Pressure Lowering Agents. Monitor therapy
Hyaluronidase: May enhance the adverse/toxic effect of Local Anesthetics. Monitor therapy
Hypotension-Associated Agents: Blood Pressure Lowering Agents may enhance the hypotensive effect of Hypotension-Associated Agents. Monitor therapy
Levodopa-Containing Products: Blood Pressure Lowering Agents may enhance the hypotensive effect of Levodopa-Containing Products. Monitor therapy
Lormetazepam: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Monitor therapy
Methemoglobinemia Associated Agents: May enhance the adverse/toxic effect of Local Anesthetics. Specifically, the risk for methemoglobinemia may be increased. Monitor therapy
Molsidomine: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Monitor therapy
Naftopidil: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Monitor therapy
Neuromuscular-Blocking Agents: Local Anesthetics may enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Monitor therapy
Nicergoline: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Monitor therapy
Nicorandil: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Monitor therapy
Nitroprusside: Blood Pressure Lowering Agents may enhance the hypotensive effect of Nitroprusside. Monitor therapy
Obeticholic Acid: May increase the serum concentration of CYP1A2 Substrates (High risk with Inhibitors). Monitor therapy
Obinutuzumab: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Management: Consider temporarily withholding blood pressure lowering medications beginning 12 hours prior to obinutuzumab infusion and continuing until 1 hour after the end of the infusion. Consider therapy modification
Peginterferon Alfa-2b: May increase the serum concentration of CYP1A2 Substrates (High risk with Inhibitors). Monitor therapy
Pentoxifylline: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Monitor therapy
Pholcodine: Blood Pressure Lowering Agents may enhance the hypotensive effect of Pholcodine. Monitor therapy
Phosphodiesterase 5 Inhibitors: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Monitor therapy
Propofol: May increase the serum concentration of Ropivacaine. Monitor therapy
Prostacyclin Analogues: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Monitor therapy
Quinagolide: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Monitor therapy
Technetium Tc 99m Tilmanocept: Local Anesthetics may diminish the diagnostic effect of Technetium Tc 99m Tilmanocept. Management: Avoid mixing and simultaneously co-injecting technetium Tc 99m tilmanocept with local anesthetics. This interaction does not appear to apply to other uses of these agents in combination. Monitor therapy
Vemurafenib: May increase the serum concentration of CYP1A2 Substrates (High risk with Inhibitors). Management: Consider alternatives to such combinations whenever possible, particularly if the CYP1A2 substrate has a relatively narrow therapeutic index. Drugs listed as exceptions to this monograph are discussed in separate drug interaction monographs. Consider therapy modification
Cardiovascular: Hypotension (32% to 69%), bradycardia (6% to 20%)
Gastrointestinal: Nausea (13% to 25%), vomiting (7% to 12%)
Neuromuscular & skeletal: Back pain (4% to 16%)
1% to 10%:
Cardiovascular: Chest pain (1% to 5%), hypertension (1% to 5%), tachycardia (1% to 5%)
Central nervous system: Headache (5% to 8%), pain (4% to 8%), paresthesia (2% to 6%), dizziness (3%), chills (≤3%), rigors (≤3%), hypoesthesia (2%), anxiety (1%)
Dermatologic: Pruritus (1% to 5%)
Endocrine & metabolic: Hypokalemia (1% to 5%)
Genitourinary: Oliguria (1% to 5%), urinary retention (1% to 5%), urinary tract infection (1% to 5%), disorder of breast milk secretion (1%), poor progression of labor (1%)
Hematologic & oncologic: Anemia (6%)
Neuromuscular & skeletal: Muscle cramps (1% to 5%)
Respiratory: Dyspnea (1% to 5%), rhinitis (1%)
Miscellaneous: Fever (2% to 9%), postoperative complication (3% to 7%)
<1%, postmarketing, and/or case reports: Accidental injury, agitation, amnesia, angioedema, asthenia, atrial fibrillation, auditory disturbance, blepharoptosis, bronchospasm, cardiac arrhythmia, coma, confusion, cough, deep vein thrombosis, drowsiness, dyskinesia, ECG abnormality, emotional lability, extrasystoles, fecal incontinence, hallucination, Horner's syndrome, hypersensitivity reaction, hypokinesia, hypomagnesemia, hypothermia, hypotonia, insomnia, jaundice, malaise, myalgia, myocardial infarction, nervousness, neuropathy, nightmares, orthostatic hypotension, pain at injection site, paresis, phlebitis, pulmonary embolism, seizure, skin rash, ST segment changes on ECG, stupor, syncope, tenesmus, tinnitus, tremor, urinary incontinence, urination disorder, urticaria, uterine atony, vertigo, visual disturbance
Concerns related to adverse effects:
• CNS toxicity: Careful and constant monitoring of the patient's state of consciousness should be done following each local anesthetic injection; at such times, restlessness, anxiety, tinnitus, dizziness, blurred vision, tremors, depression, or drowsiness may be early warning signs of CNS toxicity. Treatment is primarily symptomatic and supportive.
• Intra-articular infusion related chondrolysis: Continuous intra-articular infusion of local anesthetics after arthroscopic or other surgical procedures is not an approved use; chondrolysis (primarily in the shoulder joint) has occurred following infusion, with some cases requiring arthroplasty or shoulder replacement.
• Methemoglobinemia: Has been reported with local anesthetics; clinically significant methemoglobinemia requires immediate treatment along with discontinuation of the anesthetic and other oxidizing agents. Onset may be immediate or delayed (hours) after anesthetic exposure. Patients with glucose-6-phosphate dehydrogenase deficiency, congenital or idiopathic methemoglobinemia, cardiac or pulmonary compromise, exposure to oxidizing agents or their metabolites, or infants <6 months of age are more susceptible and should be closely monitored for signs and symptoms of methemoglobinemia (eg, cyanosis, headache, rapid pulse, shortness of breath, lightheadedness, fatigue).
• Respiratory arrest: Local anesthetics have been associated with rare occurrences of sudden respiratory arrest.
• Seizures: Convulsions due to systemic toxicity leading to cardiac arrest have also been reported, presumably following unintentional intravascular injection.
• Cardiovascular disease: Use with caution in patients with hypotension, hypovolemia, heart block, or cardiovascular disease; may be at greater risk for toxicity.
• Hepatic impairment: Use with caution in patients with hepatic impairment; may be at greater risk for toxicity.
• Neurological disorders: Use with caution in patients with neurological disorders; may be at greater risk for toxicity.
• Porphyria: Use with caution in patients with acute porphyria; consider use of alternative agents.
• Psychiatric disorders: Use with caution in patients with psychiatric disorders; may be at greater risk for toxicity.
• Renal impairment: Use with caution in patients with severe renal impairment; may be at greater risk for toxicity.
Concurrent drug therapy issues:
• Drug-drug interactions: Potentially significant interactions may exist, requiring dose or frequency adjustment, additional monitoring, and/or selection of alternative therapy. Consult drug interactions database for more detailed information.
• Acutely ill patients: Use with caution in acutely ill; may be at greater risk for toxicity.
• Debilitated patients: Use with caution in debilitated patient; may be at greater risk for toxicity.
• Elderly: Use with caution in the elderly: may be at greater risk for toxicity. Cardiovascular adverse events (bradycardia, hypotension) may be age-related (more common in patients >61 years of age).
• Administration: Intravascular injections should be avoided; aspiration should be performed prior to administration; the needle must be repositioned until no return of blood can be elicited by aspiration; however, absence of blood in the syringe does not guarantee that intravascular injection has been avoided.
• Rapid administration: Ropivacaine is not recommended for use in emergency situations where rapid administration is necessary.
• Trained personnel: Clinicians using local anesthetic agents should be well trained in diagnosis and management of emergencies that may arise from the use of these agents. Resuscitative equipment, oxygen, and other resuscitative drugs should be available for immediate use.
Heart rate, blood pressure, ECG monitoring (if used with antiarrhythmics)
Pregnancy Risk Factor
Adverse events have not been observed in animal reproduction studies. When used for epidural block during labor and delivery, systemically absorbed ropivacaine may cross the placenta, resulting in varying degrees of fetal or neonatal effects (eg, CNS or cardiovascular depression). Fetal or neonatal adverse events include fetal bradycardia (12%), neonatal jaundice (8%), low Apgar scores (3%), fetal distress (2%), neonatal respiratory disorder (3%). Maternal hypotension may also result from systemic absorption. In cases of hypotension, position pregnant woman in left lateral decubitus position to prevent aortocaval compression by the gravid uterus. Epidural anesthesia may prolong the second stage of labor.
• Discuss specific use of drug and side effects with patient as it relates to treatment. (HCAHPS: During this hospital stay, were you given any medicine that you had not taken before? Before giving you any new medicine, how often did hospital staff tell you what the medicine was for? How often did hospital staff describe possible side effects in a way you could understand?)
• Patient may experience headache, nausea, vomiting, or back pain. Have patient report immediately to prescriber signs of acidosis (confusion, fast breathing, tachycardia, abnormal heartbeat, severe abdominal pain, nausea, vomiting, fatigue, shortness of breath, or loss of strength and energy), signs of methemoglobinemia (blue or gray color of the lips, nails, or skin; abnormal heartbeat; seizures; severe dizziness or passing out; severe headache; fatigue; loss of strength and energy; or shortness of breath), severe loss of strength and energy, bradycardia, change in balance, burning or numbness feeling, numbness or tingling in mouth, lightheadedness, confusion, agitation, anxiety, difficulty speaking, metallic taste, blurred vision, tinnitus, dizziness, passing out, tremors, twitching, fatigue, depression, seizures, difficulty breathing, slow breathing, or shallow breathing (HCAHPS).
• Educate patient about signs of a significant reaction (eg, wheezing; chest tightness; fever; itching; bad cough; blue skin color; seizures; or swelling of face, lips, tongue, or throat). Note: This is not a comprehensive list of all side effects. Patient should consult prescriber for additional questions.
Intended Use and Disclaimer: Should not be printed and given to patients. This information is intended to serve as a concise initial reference for health care professionals to use when discussing medications with a patient. You must ultimately rely on your own discretion, experience, and judgment in diagnosing, treating, and advising patients.
Always consult your healthcare provider to ensure the information displayed on this page applies to your personal circumstances.
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Other brands: Naropin