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Meftah M, Boenerjous-Abel S, Siddappa VH, Kirschenbaum IH. Efficacy of Adductor Canal Block With Liposomal Bupivacaine: A Randomized Prospective Clinical Trial. Orthopedics 2020; 43:e47-e53. [PMID: 31770446 DOI: 10.3928/01477447-20191122-05] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 11/16/2018] [Indexed: 02/03/2023]
Abstract
This study compared the postoperative analgesic efficacy of liposomal bupivacaine as a single-administration adductor canal block (ACB) vs periarticular injection (PAI) for pain control after total knee arthroplasty (TKA). From May 2016 to June 2017, a total of 70 unilateral TKA patients were randomized into 2 groups: PAI (extended-release bupivacaine 266 mg [20-mL vial] with 20 mL of 0.5% bupivacaine hydrochloride and normal saline to a total volume of 120 mL) and ACB (subsartorial saphenous nerve using extended-release bupivacaine 266 mg [20-mL vial]). All patents underwent spinal anesthesia with comprehensive preemptive and postoperative multi-modal pain protocol. All opioids administered were converted to morphine equivalents. Pain was recorded at 4 to 12 hours on the day of surgery, and on postoperative days 1, 2, and 3. Patients and investigators other than the surgeon and anesthesiologist were blinded to the study. The difference in pain scores between the PAI and ACB groups was not statistically significant during the first 12 hours (day 0) after surgery or on postoperative day 1 (5.31 vs 4.26, P=.091). However, on postoperative day 3, the mean pain score increased in the ACB group and decreased in the PAI group (4.8 vs 1.83, P=.037). There was no statistically significant difference between the 2 groups regarding the accumulative daily converted morphine equivalent consumption or total consumption. Although the PAI group demonstrated longer lasting pain relief than the ACB group for the duration of the study, other outcomes were similar between the 2 groups. [Orthopedics. 2020; 43(1):e47-e53.].
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Patel RA, Jablonka EM, Rustad KC, Pridgen BC, Sorice-Virk SS, Borrelli MR, Khosla RK, Lorenz HP, Momeni A, Wan DC. Retrospective cohort-based comparison of intraoperative liposomal bupivacaine versus bupivacaine for donor site iliac crest analgesia during alveolar bone grafting. J Plast Reconstr Aesthet Surg 2019; 72:2056-2063. [DOI: 10.1016/j.bjps.2019.09.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 08/26/2019] [Accepted: 09/20/2019] [Indexed: 12/28/2022]
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Bowlby MA, Crawford ME. Opioid Crisis and Acute Pain Management After Foot and Ankle Surgery. Clin Podiatr Med Surg 2019; 36:695-705. [PMID: 31466576 DOI: 10.1016/j.cpm.2019.06.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Opioid abuse has plagued the United States, with a resurgence since the early 2000s. Governmental agencies, pharmaceutical companies, patients, and physicians have all contributed to this crisis. Severe pain has been reported following foot and ankle surgery. There are current national guidelines for chronic opioid prescribing, but guidelines for acute pain have not been established. Prescribing fewer opioids, education on opioid risks, proper disposal of unused medication, and participating in prescription monitoring programs help reduce opioid abuse. Multimodal analgesia is paramount in managing pain while reducing opioid consumption after postoperative foot and ankle surgery.
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Affiliation(s)
- Melinda A Bowlby
- Department of Orthopedics, Division of Podiatry, Swedish Medical Center, Seattle, WA, USA; Department of Orthopedics, Division of Podiatry, Providence Medical Center, Everett, WA, USA; Private Practice, The Ankle and Foot Clinic of Everett, 3131 Nassau Street Suite 101, Everett, WA 98201, USA.
| | - Mary E Crawford
- Department of Orthopedics, Division of Podiatry, Providence Medical Center, Everett, WA, USA; Private Practice, The Ankle and Foot Clinic of Everett, 3131 Nassau Street Suite 101, Everett, WA 98201, USA
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Purcell RL, Brooks DI, Steelman TJ, Christensen DL, Dickens JF, Kent ML, McCabe MP, Anderson TD. Fascia Iliaca Blockade With the Addition of Liposomal Bupivacaine Versus Plain Bupivacaine for Perioperative Pain Management During Hip Arthroscopy: A Double-Blinded Prospective Randomized Control Trial. Arthroscopy 2019; 35:2608-2616. [PMID: 31402223 DOI: 10.1016/j.arthro.2019.03.056] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 03/21/2019] [Accepted: 03/24/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE To determine in a prospective, randomized fashion whether liposomal bupivacaine extends the effectiveness of decreased pain scores and reduces narcotic requirements following hip arthroscopy when used in addition to a fascia iliaca blockade with plain bupivacaine alone. METHODS Double-blinded prospective randomized controlled trial of participants undergoing hip arthroscopy. Randomized to receive a fascia iliaca blockade with 40 mL 0.25% plain bupivacaine (100 mg; control group) or 20 mL 0.5% plain bupivacaine (100 mg) plus 20 mL liposomal bupivacaine (266 mg; study group). The primary outcome was Defense and Veterans Pain Rating Scale (DVPRS) scores in the postanesthesia care unit and on postoperative days (POD) 1, 2, 3, and 14. Secondary outcomes included postoperative opioid consumption and subjective loss of anterior thigh sensation. RESULTS Seventy-four patients were enrolled, and 70 completed the study; 37 were randomized to the control group and 33 to the study group. There was no significant difference in postoperative DVPRS scores at any time point. There was no significant difference in total postoperative opioid use during any postoperative time points. While most patients reported anterior thigh numbness at discharge, significantly more patients in the study group reported anterior thigh numbness at POD2 (control, 19/37 numb vs study, 32/33 numb; P < .0001) and at POD3 (control, 8/37 numb vs study, 26/33 numb; P < .0001). CONCLUSIONS In this prospective evaluation comparing plain bupivacaine versus the liposomal formulation administered via a fascia iliaca blockade there were no significant differences in postoperative pain scores and narcotic pill usage. Given the highly significant findings of prolonged anterior thigh numbness out to POD3 in patients who received liposomal bupivacaine, this formulation did exhibit prolonged effects; however, it did not provide improved pain control when used in this surgical population, likely due to the innervation of the hip capsule from differential nerve plexi. Given the 6-fold increased cost of using the liposomal formulation, we are unable to recommend its use via a fascia iliaca blockade for hip arthroscopy. LEVEL OF EVIDENCE Level I, therapeutic study.
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Affiliation(s)
- Richard L Purcell
- Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, Maryland, U.S.A..
| | - Daniel I Brooks
- Department of Research Programs, Walter Reed National Military Medical Center, Bethesda, Maryland, U.S.A
| | - Theodore J Steelman
- Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, Maryland, U.S.A
| | - Daniel L Christensen
- Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, Maryland, U.S.A
| | - Jonathan F Dickens
- Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, Maryland, U.S.A
| | - Michael L Kent
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina, U.S.A
| | - Michael P McCabe
- APEX Orthopedic and Sports Medicine, Overland Park, Kansas, U.S.A
| | - Terrence D Anderson
- Department of Orthopedic Surgery, University of Texas Health Science Center at Houston (T.D.A.), Houston, Texas, U.S.A
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Abstract
Local anesthetics are the only class of drugs that can block transduction and transmission of nociception. Physical properties, mechanism of action, and pharmacokinetics of this class of drugs are reviewed in this article. The clinical use, such intravenous administration of lidocaine, and local and systemic toxic effects are covered. A review of current studies published in the human and veterinary literature on lidocaine patches (Lidoderm) and liposomal bupivacaine (Experal and Nocita) are discussed.
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Abildgaard JT, Chung AS, Tokish JM, Hattrup SJ. Clinical Efficacy of Liposomal Bupivacaine. JBJS Rev 2019; 7:e8. [DOI: 10.2106/jbjs.rvw.18.00192] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Tran BW, Liebman ST, Reichman TW, Scott MJ. Hemodynamic Instability and Lipid Emulsion Resuscitation After Subcutaneous Injection of a Liposomal Bupivacaine Admixture: A Case Report. A A Pract 2019; 12:223-225. [DOI: 10.1213/xaa.0000000000000889] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Brown L, Weir T, Koenig S, Shasti M, Yousaf I, Yousaf O, Tannous O, Koh E, Banagan K, Gelb D, Ludwig S. Can Liposomal Bupivacaine Be Safely Utilized in Elective Spine Surgery? Global Spine J 2019; 9:133-137. [PMID: 30984490 PMCID: PMC6448202 DOI: 10.1177/2192568218755684] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
STUDY DESIGN Single-blinded prospective randomized control trial. OBJECTIVES To compare the incidence of adverse events (AEs) and hospital length of stay between patients who received liposomal bupivacaine (LB) versus a single saline injection, following posterior lumbar decompression and fusion surgery for degenerative spondylosis. METHODS From 2015 to 2016, 59 patients undergoing posterior lumbar decompression and fusion surgery were prospectively enrolled and randomized to receive either 60 mL injection of 266 mg LB or 60 mL of 0.9% sterile saline, intraoperatively. Outcome measures included the incidence of postoperative AEs and hospital length of stay. RESULTS The most common AEs in the treatment group were nausea (39.3%), emesis (18.1%), and hypotension (18.1%). Nausea (23%), constipation (19.2%), and urinary retention (15.3%) were most common in the control group. Patients who received LB had an increased risk of developing nausea (relative risk [RR] = 1.7; 95% confidence interval [CI] = 0.75-3.8), emesis (RR = 2.3; 95% CI = 0.51-10.7), and headaches (RR = 2.36; 95% CI = 0.26-21.4). Patients receiving LB had a decreased risk of developing constipation (RR = 0.78; 95% CI = 0.25-2.43), urinary retention (RR = 0.78; 95% CI = 0.21-2.85), and pruritus (RR = 0.78; 95% = 0.21-2.8) postoperatively. Relative risk values mentioned above failed to reach statistical significance. No significant difference in the hospital length of stay between both groups was found (3.9 vs 3.9 days; P = .92). CONCLUSION Single-dose injections of LB to the surgical site prior to wound closure did not significantly increase or decrease the incidence or risk of developing AEs postoperatively. Furthermore, no significant difference was found in the hospital length of stay between both groups.
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Affiliation(s)
- Luke Brown
- University of Maryland School of Medicine, Baltimore, MD, USA
| | - Tristan Weir
- University of Maryland School of Medicine, Baltimore, MD, USA
| | - Scott Koenig
- University of Maryland School of Medicine, Baltimore, MD, USA
| | - Mark Shasti
- University of Maryland School of Medicine, Baltimore, MD, USA
| | - Imran Yousaf
- University of Maryland School of Medicine, Baltimore, MD, USA
| | - Omer Yousaf
- University of Maryland School of Medicine, Baltimore, MD, USA
| | - Oliver Tannous
- University of Maryland School of Medicine, Baltimore, MD, USA
| | - Eugene Koh
- University of Maryland School of Medicine, Baltimore, MD, USA
| | - Kelley Banagan
- University of Maryland School of Medicine, Baltimore, MD, USA
| | - Daniel Gelb
- University of Maryland School of Medicine, Baltimore, MD, USA
| | - Steven Ludwig
- University of Maryland School of Medicine, Baltimore, MD, USA,Steven Ludwig, Department of Orthopaedics,
University of Maryland Medical Center, 110 South Paca Street, 6th Floor Suite 300,
Baltimore, MD 21201, USA.
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Liposomal Bupivacaine Versus Standard Periarticular Injection in Total Knee Arthroplasty With Regional Anesthesia: A Prospective Randomized Controlled Trial. J Arthroplasty 2019; 34:488-494. [PMID: 30554925 DOI: 10.1016/j.arth.2018.11.026] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 10/22/2018] [Accepted: 11/19/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Liposomal bupivacaine (Exparel) is a long-acting local anesthetic preparation with demonstrated efficacy over placebo in reducing postoperative pain and opioid requirement. Limited comparative efficacy and cost-effectiveness data exist for its use in total knee arthroplasty (TKA) when used in a multimodal, opioid-sparing analgesic and anesthetic approach. We hypothesized that liposomal bupivacaine offers no clinical advantage over our standard of care but carries significant economic impact. METHODS This is a prospective, randomized, single-blinded, controlled trial comparing liposomal bupivacaine periarticular injection (PAI) to our current approach including conventional bupivacaine PAI, in the setting of regional anesthesia. All adult unilateral TKA patients of the collaborating surgeon were eligible to participate in the study. Patients were randomized 1:1 to either the liposomal bupivacaine protocol or the standard-of-care protocol. All patients received regional anesthesia and standard postoperative analgesia protocols. Patients and all postoperative healthcare providers were blinded to study arm assignment. RESULTS A total of 59 patients were enrolled per our a priori power calculation after 1 exclusion for randomization error. No significant demographic differences between the study arms were found. There was no statistically significant difference in the primary outcome of number of physical therapy (PT) sessions required to achieve home-going discharge goals (3.0 ± 1.2 vs 3.6 ± 1.3, P = .137), nor in the clinical secondary outcomes. A significant difference in medication charges was found. CONCLUSION Our study supports earlier literature suggesting no significant clinical benefit of using liposomal bupivacaine over standard of care in TKA and underscores cost-of-care concerns with this agent.
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Neurological and histological outcomes after subarachnoid injection of a liposomal bupivacaine suspension in pigs: a pilot study. Br J Anaesth 2019; 122:379-387. [DOI: 10.1016/j.bja.2018.10.025] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 10/18/2018] [Accepted: 10/19/2018] [Indexed: 11/16/2022] Open
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Damjanovska M, Cvetko E, Kuroda MM, Seliskar A, Plavec T, Mis K, Podbregar M, Pintaric TS. Neurotoxicity of intraneural injection of bupivacaine liposome injectable suspension versus bupivacaine hydrochloride in a porcine model. Vet Anaesth Analg 2019; 46:236-245. [DOI: 10.1016/j.vaa.2018.09.044] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Revised: 09/04/2018] [Accepted: 09/20/2018] [Indexed: 10/28/2022]
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Marino J, Scuderi G, Dowling O, Farquhar R, Freycinet B, Overdyk F. Periarticular Knee Injection With Liposomal Bupivacaine and Continuous Femoral Nerve Block for Postoperative Pain Management After Total Knee Arthroplasty: A Randomized Controlled Trial. J Arthroplasty 2019; 34:495-500. [PMID: 30583813 DOI: 10.1016/j.arth.2018.11.025] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Revised: 10/29/2018] [Accepted: 11/19/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Local periarticular infiltration (PAI) analgesia has emerged as an important component of multimodal approaches to treat total knee arthroplasty postoperative pain. Liposomal bupivacaine may provide prolonged analgesic duration when injected into the surrounding tissues. The purpose of this study was to compare the analgesic efficacy and serum bupivacaine levels of a continuous femoral nerve block (CFNB) with bupivacaine to PAI with liposomal bupivacaine. METHODS Sixty-five patients undergoing primary unilateral total knee arthroplasty were randomized into 2 groups: (1) CFNB and PAI with bupivacaine (CFNB group) or (2) PAI with bupivacaine:liposomal bupivacaine mixture at the end of surgery (LB group). The primary outcome was pain intensity at maximum knee flexion 24 hours following surgery. Secondary outcomes included pain intensities at rest and movement at timed intervals and serum bupivacaine levels. RESULTS Patients in the CFNB group experienced lower pain scores at maximum knee flexion at 24 hours (7.91; 95% confidence interval, 7.19-8.61) compared to the LB group (8.95; 95% confidence interval, 8.42-9.48; P = .02). The mean peak serum bupivacaine level in the LB group up to 72 hours was 0.55 μg/mL versus 1.4 μg/mL for CFNB group (P = .0008) with one patient in the CFNB group exceeding the reported minimum serum bupivacaine threshold for toxicity. CONCLUSION While similar pain control was observed on the day of surgery for both groups, patients with a CFNB experienced lower pain intensities during maximum knee flexion at 24 hours. Total serum concentrations in LB group remained below the toxicity threshold over the study period.
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Affiliation(s)
- Joseph Marino
- Department of Anesthesiology, Zucker School of Medicine, Long Island Jewish Valley Stream, Valley Stream, NY
| | - Giles Scuderi
- Orthopedic Service Line, Northwell Health, New York, NY
| | - Oonagh Dowling
- Department of Anesthesiology, Zucker School of Medicine, New Hyde Park, NY
| | - Rena Farquhar
- Department of Anesthesiology, Zucker School of Medicine, Northwell Health, Long Island Jewish Valley Stream, Valley Stream NY
| | - Bridget Freycinet
- Department of Anesthesiology, Zucker School of Medicine, Northwell Health, Long Island Jewish Valley Stream, Valley Stream NY
| | - Frank Overdyk
- Department of Anesthesiology, Trident Anesthesiology Group, Charleston, SC
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Coppens SJ, Zawodny Z, Dewinter G, Neyrinck A, Balocco AL, Rex S. In search of the Holy Grail: Poisons and extended release local anesthetics. Best Pract Res Clin Anaesthesiol 2019; 33:3-21. [DOI: 10.1016/j.bpa.2019.03.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 03/12/2019] [Indexed: 11/17/2022]
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Cohen B, Glosser L, Saab R, Walters M, Salih A, Zafeer-Khan M, Rivas E, Zhang K, Schacham NY, Chodavarapu P, Essber H, Chelnick D, Raza S, Hanline C, Khoshknabi D, Yang D, Seif J, Chhabada S, Turan A. Incidence of adverse events attributable to bupivacaine liposome injectable suspension or plain bupivacaine for postoperative pain in pediatric surgical patients: A retrospective matched cohort analysis. Paediatr Anaesth 2019; 29:169-174. [PMID: 30521078 DOI: 10.1111/pan.13561] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Revised: 11/19/2018] [Accepted: 11/29/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Surgical wound infiltration with local anesthetics is common as part of multimodal analgesia and enhanced recovery pathways in pediatric surgical patients. Liposomal bupivacaine can provide up to 92 hours of pain relief, and was approved by the U.S Food and Drug Administration for local infiltration in adults. It is also commonly used by pediatric surgeons, but its safety profile in this age group has not been described. AIMS The aim of this study was to describe the incidence of local anesthetic systemic toxicity syndrome in pediatric surgical patients receiving liposomal bupivacaine compared to plain bupivacaine for surgical wound infiltration. METHODS We conducted a retrospective, single center, assessor blinded cohort study of pediatric surgical inpatients having open or laparoscopic surgery in the Cleveland Clinic between 2013 and 2017 and receiving wound infiltration with local anesthetics. We compared the incidence of local anesthetic systemic toxicity among those who received any dose of liposomal bupivacaine and those who received plain bupivacaine. Groups were matched 1:2 according to procedure type, age, and physical status score. Local anesthetic systemic toxicity was primarily defined as at least two signs or symptoms possibly related to anesthetic toxicity, as judged by two independent adjudicators blinded to the type of local anesthetic. A sensitivity analysis compared the incidence of a single sign/symptom possibly related to anesthetic toxicity. RESULTS A total of 924 surgical cases were included in the final analysis (356 liposomal bupivacaine and 568 plain bupivacaine cases). The primary outcome did not occur in any patient. The sensitivity analysis found three cases in the liposomal bupivacaine group and two cases in the plain bupivacaine group having a single sign/symptom possibly related to local anesthetic administration (relative risk 2.4, 95% CI 0.4-14.0, P = 0.38). CONCLUSION In a cohort of pediatric surgical patients receiving wound infiltration with either plain or liposomal bupivacaine, we identified no cases of local anesthetic systemic toxicity syndrome, and only few patients with any sign or symptom that could potentially be related to local anesthetic toxicity.
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Affiliation(s)
- Barak Cohen
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio.,Division of Anesthesia, Critical Care and Pain Management, Tel-Aviv Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Logan Glosser
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio
| | - Remie Saab
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio
| | - Michael Walters
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio
| | - Ahmed Salih
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio
| | | | - Eva Rivas
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio.,Department of Anesthesiology, Hospital Clinic of Barcelona, IDIBPAS, University of Barcelona, Barcelona, Spain
| | - Kan Zhang
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio
| | - Nadav Y Schacham
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio.,Internal Medicine C, Sheba Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | | | - Hani Essber
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio
| | - David Chelnick
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio
| | - Syed Raza
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio
| | - CeCelia Hanline
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio
| | | | - Dongsheng Yang
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio.,Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - John Seif
- Department of General anesthesia, Cleveland Clinic, Cleveland, Ohio.,Department of Pediatric anesthesia, Cleveland Clinic, Cleveland, Ohio
| | | | - Alparslan Turan
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio.,Department of General anesthesia, Cleveland Clinic, Cleveland, Ohio
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Cloyd C, Moffett BS, Bernhardt MB, Monico EM, Patel N, Hanson D. Efficacy of liposomal bupivacaine in pediatric patients undergoing spine surgery. Paediatr Anaesth 2018; 28:982-986. [PMID: 30207019 DOI: 10.1111/pan.13482] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Revised: 07/30/2018] [Accepted: 08/04/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Liposomal bupivacaine may be an option for reducing opioid utilization in pediatric scoliosis surgery. The use of liposomal bupivacaine in this patient population has not been previously described. METHODS Patients who underwent posterior spinal fusion surgery at our institution from 2011-2016 were identified. We performed a retrospective matched cohort study, matching patients who received intraoperative liposomal bupivacaine by age, gender, and extent of surgery to patients who did not. The primary endpoint was the use of morphine equivalents in the first 72 hours after surgery. Data collection included demographic and surgical data, pain medication utilization, and pain scores. Area under the curve (AUC) for pain scores was calculated. Descriptive statistical methods and univariable analysis were used to compare patients who received liposomal bupivacaine to patients who did not. RESULTS One hundred and forty-one patients met study criteria; 47 patients who received liposomal bupivacaine were matched to 94 control patients who did not receive liposomal bupivacaine. No significant differences were noted in the patient population with the patients requiring a median of 11 segments (range 10-13 segments) fused. Patients received a mean of 56.6 ± 37.4 mg/kg of intravenous acetaminophen, a mean of 3.4 ± 2.1 mg/kg of intravenous ketorolac, and 1.9 ± 0.93 mg/kg of morphine equivalents in the first 72 hours after surgery. On univariable analysis, no differences were noted in intravenous acetaminophen use, pain score AUC, intravenous ketorolac use, or morphine equivalents (2.0 ± 98 vs 1.8 ± 0.82) in patients who did not receive liposomal bupivacaine as compared to those patient who did received liposomal bupivacaine. CONCLUSION Liposomal bupivacaine was not associated with reductions in postoperative opioid use in pediatric spinal surgery.
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Extended Release Liposomal Bupivacaine Injection (Exparel) for Early Postoperative Pain Control Following Palatoplasty. J Craniofac Surg 2018; 29:e525-e528. [PMID: 29762332 DOI: 10.1097/scs.0000000000004591] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Liposomal bupivacaine (LB) is a long-acting local anesthetic reported to decrease postoperative pain in adults. The authors demonstrate the safe use of LB in pediatric patients with improved pain control following palatoplasty. MATERIALS AND METHODS Retrospective patient series of all single-surgeon palatoplasty patients treated at a tertiary craniofacial center from August 2014 to December 2015 were included. All patients received 1.3% LB intraoperatively as greater palatal nerve and surgical field blocks in 2-flap V-Y pushback palatoplasty. Postoperative oral intake, opioids administered, duration of hospitalization, and FLACC (face, legs, activity, cry, consolability) pain scores were measured. RESULTS Twenty-seven patients (16 males and 11 females, average age of 10.8 months, weight 8.8 kg) received 2.9 ± 0.9 mL (2.6 ± 1.9 mg/kg) 1.3% LB. Average FLACC scores were 2.4 ± 2.2/10 in the postanesthesia care unit and 3.8 ± 1.8/10 while inpatients. Oral intake was first tolerated 10.3 ± 11.5 hours postoperatively and tolerated 496.4 ± 354.2 mL orally in the first 24 hours postoperatively. Patients received 8.5 ± 8.4 mg hydrocodone equivalents (0.46 ± 0.45 mg/kg per d hydrocodone equivalents) and were discharged 2.1 ± 1.3 days postoperatively. Opioid-related adverse events included emesis in 7.4% and pruritis in 3.7% of patients. CONCLUSIONS The LB may be used safely in pediatric patients. Intraoperative injection of LB during palatoplasty can yield low postoperative opioid use and an early and adequate volume of oral intake over an average hospital stay. Further cost-efficacy studies of LB are needed to assess its value in pediatric plastic surgery.
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Pichler L, Poeran J, Zubizarreta N, Cozowicz C, Sun EC, Mazumdar M, Memtsoudis SG. Liposomal Bupivacaine Does Not Reduce Inpatient Opioid Prescription or Related Complications after Knee Arthroplasty: A Database Analysis. Anesthesiology 2018; 129:689-699. [PMID: 29787389 PMCID: PMC6148397 DOI: 10.1097/aln.0000000000002267] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
WHAT WE ALREADY KNOW ABOUT THIS TOPIC WHAT THIS MANUSCRIPT TELLS US THAT IS NEW: BACKGROUND:: Although some trials suggest benefits of liposomal bupivacaine, data on real-world use and effectiveness is lacking. This study analyzed the impact of liposomal bupivacaine use (regardless of administration route) on inpatient opioid prescription, resource utilization, and opioid-related complications among patients undergoing total knee arthroplasties with a peripheral nerve block. It was hypothesized that liposomal bupivacaine has limited clinical influence on the studied outcomes. METHODS The study included data on 88,830 total knee arthroplasties performed with a peripheral nerve block (Premier Healthcare Database 2013 to 2016). Multilevel multivariable regressions measured associations between use of liposomal bupivacaine and (1) inpatient opioid prescription (extracted from billing) and (2) length of stay, cost of hospitalization, as well as opioid-related complications. To reflect the difference between statistical and clinical significance, a relative change of -15% in outcomes was assumed to be clinically important. RESULTS Overall, liposomal bupivacaine was used in 21.2% (n = 18,817) of patients that underwent a total knee arthroplasty with a peripheral nerve block. Liposomal bupivacaine use was not associated with a clinically meaningful reduction in inpatient opioid prescription (group median, 253 mg of oral morphine equivalents, adjusted effect -9.3% CI -11.1%, -7.5%; P < 0.0001) and length of stay (group median, 3 days, adjusted effect -8.8% CI -10.1%, -7.5%; P < 0.0001) with no effect on cost of hospitalization. Most importantly, liposomal bupivacaine use was not associated with decreased odds for opioid-related complications. CONCLUSIONS Liposomal bupivacaine was not associated with a clinically relevant improvement in inpatient opioid prescription, resource utilization, or opioid-related complications in patients who received modern pain management including a peripheral nerve block.
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Affiliation(s)
- Lukas Pichler
- From the Department of Anesthesiology, Hospital for Special Surgery, Weill Cornell Medical College, New York, New York (L.P., C.C., S.G.M.) Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria (L.P., C.C., S.G.M.) Icahn School of Medicine at Mount Sinai, New York, New York (J.P., N.Z., M.M.) Stanford University, Stanford, California (E.C.S.)
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Sun H, Li S, Wang K, Zhou J, Wu G, Fang S, Sun X. Do liposomal bupivacaine infiltration and interscalene nerve block provide similar pain relief after total shoulder arthroplasty: a systematic review and meta-analysis. J Pain Res 2018; 11:1889-1900. [PMID: 30271195 PMCID: PMC6151095 DOI: 10.2147/jpr.s177716] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE Controversy still exists regarding the efficiency and safety of liposomal bupivacaine (LB) vs interscalene nerve block (INB) for pain management after total shoulder arthroplasty (TSA). The aim of the present meta-analysis was to perform a relatively credible and overall assessment to compare the efficiency and safety of LB-based infiltration vs INB for pain management after TSA. METHODS The PubMed, Cochrane Library, Web of Science, and EMBASE were systematically searched. Only studies published up to March 2018 comparing LB vs INB for pain control after TSA were included. The primary outcome extracted from the studies was postoperative pain score at different periods. The secondary outcomes included total opioid consumption, length of hospital stay, and complications. RESULTS Seven studies with 707 patients were included in this study. No statistically significant difference was observed between the LB and INB groups in pain scores at 8 hours, 12 hours, 24 hours, postoperative day (POD) 1, and POD 2. The two groups also showed comparable total opioid consumption at POD 0, POD 1, POD 2, and length of hospital stay. The LB group had a significantly higher pain score at 4 hours (standard mean difference =0.65, 95% CI=0.07 to 1.24, P=0.03) but a lower occurrence rate of complications than did the INB group (OR =0.51, 95% CI=0.28 to 0.91, P=0.02). CONCLUSION This meta-analysis revealed that INB provides excellent analgesic effects within 4 hours after TSA, while patients treated with LB infiltration experienced significantly less occurrence rate of complications after TSA. In general, both approaches provide similar overall pain relief and have similar opioid consumption after TSA, with no significant difference in the length of hospital stay. Nevertheless, more high-quality randomized controlled trails with long-term follow-up are still required to make the final conclusion.
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Affiliation(s)
- Han Sun
- Department of Articular Orthopaedics, The Third Affiliated Hospital of Soochow University, Changzhou 213003, Jiangsu, China,
| | - Shuxiang Li
- Department of Articular Orthopaedics, The Third Affiliated Hospital of Soochow University, Changzhou 213003, Jiangsu, China,
| | - Kun Wang
- Department of Articular Orthopaedics, The Third Affiliated Hospital of Soochow University, Changzhou 213003, Jiangsu, China,
| | - Jian Zhou
- Department of Articular Orthopaedics, The Third Affiliated Hospital of Soochow University, Changzhou 213003, Jiangsu, China,
| | - Guofeng Wu
- Department of Articular Orthopaedics, The Third Affiliated Hospital of Soochow University, Changzhou 213003, Jiangsu, China,
| | - Sheng Fang
- Department of Articular Orthopaedics, The Third Affiliated Hospital of Soochow University, Changzhou 213003, Jiangsu, China,
| | - Xiaoliang Sun
- Department of Articular Orthopaedics, The Third Affiliated Hospital of Soochow University, Changzhou 213003, Jiangsu, China,
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Brown L, Weir T, Shasti M, Yousaf O, Yousaf I, Tannous O, Koh E, Banagan K, Gelb D, Ludwig S. The Efficacy of Liposomal Bupivacaine in Lumbar Spine Surgery. Int J Spine Surg 2018; 12:434-440. [PMID: 30276103 DOI: 10.14444/5052] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background Postoperative pain management in spine surgery holds unique challenges. The purpose of this study is to determine if the local anesthetic liposomal bupivacaine (LB) reduces the total opioid requirement in the first 3 days following posterior lumbar decompression and fusion (PLDF) surgery for degenerative spondylosis. Methods Fifty patients underwent PLDF surgery in a prospective randomized control pilot trial between August 2015 and October 2016 and were equally allocated to either a treatment (LB) or a control (saline) group. Assessments included the 72-hour postoperative opioid requirement normalized to 1 morphine milligram equivalent (MME), visual analog scale (VAS), and hospital length of stay. Results LB did not significantly alter the 72-hour postoperative opioid requirement compared to saline (11.6 vs. 13.4 MME, P = .40). In a subgroup analysis, there was also no significant difference in opioid consumption among narcotic-naive patients with either LB or saline. Among narcotic tolerant patients, however, opioid consumption was higher with saline than LB (20.6 MME vs. 13.3 MME, P = .048). Additionally, pre- and postoperative VAS scores and hospital length of stay were not significantly different with either LB or saline. Conclusions In the setting of PLDF surgery, LB injections did not significantly reduce the consumption of opioids in the first 3 postoperative days, nor did the hospital length of stay or VAS pain scores, compared to saline. However, LB could be beneficial in reducing the consumption of opioids in narcotic-tolerant populations. Level of Evidence 2.
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Affiliation(s)
- Luke Brown
- Department of Orthopaedics, University of Maryland Medical Center, University of Maryland, Baltimore, MD
| | - Tristan Weir
- Department of Orthopaedics, University of Maryland Medical Center, University of Maryland, Baltimore, MD
| | - Mark Shasti
- Department of Orthopaedics, University of Maryland Medical Center, University of Maryland, Baltimore, MD
| | - Omer Yousaf
- Department of Orthopaedics, University of Maryland Medical Center, University of Maryland, Baltimore, MD
| | - Imran Yousaf
- Department of Orthopaedics, University of Maryland Medical Center, University of Maryland, Baltimore, MD
| | - Oliver Tannous
- Department of Orthopaedics, University of Maryland Medical Center, University of Maryland, Baltimore, MD
| | - Eugene Koh
- Department of Orthopaedics, University of Maryland Medical Center, University of Maryland, Baltimore, MD
| | - Kelley Banagan
- Department of Orthopaedics, University of Maryland Medical Center, University of Maryland, Baltimore, MD
| | - Daniel Gelb
- Department of Orthopaedics, University of Maryland Medical Center, University of Maryland, Baltimore, MD
| | - Steven Ludwig
- Department of Orthopaedics, University of Maryland Medical Center, University of Maryland, Baltimore, MD
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Namdari S, Nicholson T, Abboud J, Lazarus M, Steinberg D, Williams G. Interscalene Block with and without Intraoperative Local Infiltration with Liposomal Bupivacaine in Shoulder Arthroplasty: A Randomized Controlled Trial. J Bone Joint Surg Am 2018; 100:1373-1378. [PMID: 30106818 DOI: 10.2106/jbjs.17.01416] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Interscalene brachial plexus blockade (ISBPB) is an effective anesthetic technique for shoulder arthroplasty; however, "rebound pain" can increase the patient's postoperative pain experience and narcotic usage. Exparel (liposomal bupivacaine) injected into the soft tissues at the surgical site has theoretical efficacy for up to 72 hours after administration. The purpose of this study was to evaluate postoperative pain scores and narcotic consumption following shoulder arthroplasty performed with either ISBPB alone or ISBPB and intraoperative Exparel. METHODS Seventy-eight patients undergoing primary shoulder arthroplasty were randomized to receive an ISBPB with Exparel (39 patients) or without Exparel (39 patients). The primary outcome variable was morphine equivalent units (MEUs) consumed over the first 24 hours after surgery. Secondary outcomes included intraoperative narcotic administration and visual analog scale (VAS) scores for pain (at 0, 8, 16, 24, 48, and 72 hours after surgery). RESULTS There were no significant demographic differences between the ISBPB and ISBPB + Exparel groups. Total narcotic consumption over the first 24 hours after surgery was significantly lower in the ISBPB group compared with the ISBPB + Exparel group (mean and standard deviation, 18.9 ± 25.6 MEU versus 35.3 ± 36.7 MEU, p = 0.009). VAS pain scores did not differ significantly between groups at any time point during the first 72 hours after surgery. CONCLUSIONS Patients treated with Exparel required significantly more postoperative narcotics and demonstrated no significant reduction in pain scores over the first 72 hours after primary shoulder arthroplasty. Exparel does not appear to have substantial value when added to a pain protocol that includes an ISBPB. LEVEL OF EVIDENCE Therapeutic Level l. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Surena Namdari
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania
| | - Thema Nicholson
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania
| | - Joseph Abboud
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania
| | - Mark Lazarus
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania
| | - Dean Steinberg
- Department of Anesthesia, Sidney Kimmel Medical College at Thomas Jefferson University-Methodist Hospital Division, Philadelphia, Pennsylvania
| | - Gerald Williams
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania
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Multimodal Pain Strategies Including Liposomal Bupivacaine for Isolated Acetabular Fracture Surgery. J Orthop Trauma 2018; 32 Suppl 2:S11-S15. [PMID: 30028759 DOI: 10.1097/bot.0000000000001228] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND The incidence of isolated acetabular fractures has been increasing, particularly in older adult patients. These fractures can be debilitating and may require prolonged immobilization and/or complex surgical reconstruction. Liposomal bupivacaine (LB) is a prolonged-release form of bupivacaine demonstrated to be effective in orthopaedic surgery. Defining a multimodal pain management plan, which incorporates optimized techniques for use of LB in acetabular surgery, may improve outcomes for patients. METHODS Two orthopaedic surgeons specializing in orthopaedic traumatology discussed best practices for infiltration of LB and recommendations for perioperative use of LB plus other anesthetics/analgesics for isolated acetabular fracture surgery. RESULTS Consensus techniques for isolated posterior and anterior acetabular fractures were developed. LB (266 mg/20 mL) should be expanded with 50 mL of bupivacaine HCl 0.25% and saline to a total volume of 120 or 300 mL for the posterior or anterior techniques, respectively. A 3.5-inch spinal needle is inserted tangentially, infiltrating 1 mL/cm into the fracture site, periosteum, muscle fascia, subcutaneous tissue, and skin. Patients receive acetaminophen, celecoxib, gabapentin, and opioids before surgery, adjusting appropriately for patient comorbidities and potential drug-drug interactions. At the end of the surgery, before closure, LB is infiltrated and patients receive a dose of intravenous acetaminophen. Presurgical medications are continued after surgery for approximately 10-14 days, after which opioids are only considered to treat breakthrough pain. CONCLUSIONS These recommendations can be used to optimize and streamline care for patients with isolated acetabular fractures and act as a foundation for additional clinical research. LEVEL OF EVIDENCE Therapeutic Level V.
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Fascia iliaca blockade with the addition of liposomal bupivacaine vs. plain bupivacaine for perioperative pain management following hip arthroscopy. Knee Surg Sports Traumatol Arthrosc 2018; 26:2536-2541. [PMID: 29453489 DOI: 10.1007/s00167-018-4874-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2017] [Accepted: 02/12/2018] [Indexed: 10/18/2022]
Abstract
PURPOSE A newer formulation of bupivacaine, encapsulated within carrier molecules, has garnered attention for its role in providing extended post-operative analgesia. The purpose was to evaluate the addition of liposomal bupivacaine to fascia iliaca blockade during hip arthroscopy. METHODS Retrospective cohort study of patients undergoing hip arthroscopy with a pre-operative fascia iliaca blockade with either liposomal bupivacaine (Group 1; 266mg + 20 cc 0.5% plain bupivacaine) or bupivacaine (Group 2; 40 cc 0.25% plain bupivacaine). All patients received standardized pre-operative oral pain medications. The primary outcome was the defense veteran pain rating scale (DVPRS). Secondary outcomes included duration of hospital admission, PACU opioid use, PACU pain scores, and duration of nerve blockade. RESULTS Thirty-eight males and 30 females, mean age of 33 years (range 14-56). There was no difference in pre-operative DVPRS between the groups (n.s.). There was no difference in post-operative DVPRS pain scores at POD0 (3.7 vs. 3.9, n.s.), POD1 (4.2 vs. 3.8, n.s.), POD2 (4.2 vs. 3.7, n.s.), POD3 (3.9 vs. 3.7, n.s.) or POD14 (2.2 vs. 2.4, n.s.). Group 1 trended towards longer mean total hospital admission time (872 vs. 822 min, n.s.), and greater mean morphine equivalents administered in the PACU (33 vs. 29 mg, n.s.). 68% of patients in group 1 reported continued anterior thigh numbness at POD3, compared to 34% in group 2 (p = 0.008). CONCLUSIONS Despite the advertised benefits of prolonged post-operative analgesia using liposomal bupivacaine, there were no significant differences in post-operative pain scores or PACU opioid consumption. Our results support that acceptable pain scores are successfully achieved at all time periods with the use of multimodal analgesia including fascia iliaca blockade despite the type of pain medication administered. LEVEL OF EVIDENCE III.
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Suzuki T, Kosugi K, Suto T, Tobe M, Tabata Y, Yokoo S, Saito S. Sustained-release lidocaine sheet for pain following tooth extraction: A randomized, single-blind, dose-response, controlled, clinical study of efficacy and safety. PLoS One 2018; 13:e0200059. [PMID: 29966016 PMCID: PMC6028143 DOI: 10.1371/journal.pone.0200059] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Accepted: 06/12/2018] [Indexed: 02/07/2023] Open
Abstract
Background We have synthesized a sustained-release lidocaine sheet (SRLS) using biodegradable polymers and previously demonstrated its safety and long-term analgesic effect in the normal mucous membrane of healthy human volunteers. Objectives The aim of this clinical study was to evaluate the efficacy, safety, and appropriate dose of the SRLS for pain following tooth extraction. Design Randomized, single-blind, dose-response, controlled, clinical study (Phase 1/2). Methods The patients in this trial were enrolled between January 2014 and December 2016. A total of 99 patients were randomly divided into 5 groups as follows: the Non-administration group received the conventional extraction; the Poly Lactic-co-Glycolic Acid (PLGA) 100 mg control group received the PLGA matrix without lidocaine; the SRLS 100 mg group received a single sheet of SRLS 100 mg; the SRLS 200 mg group received double sheets of SRLS 100 mg; and the SRLS 400 mg administration group received four sheets of SRLS 100 mg. A study drug was inserted into the defect socket after the extraction, and postoperative pain intensity, satisfaction with postoperative pain relief, adverse events, and postoperative supplemental analgesic rescue use (time, dose) were investigated by patient self-report. Results In total, 94 (94.9%) patients completed the study. There were no significant differences in postoperative pain intensity, satisfaction with postoperative pain relief, and postoperative supplemental analgesic rescue use among the 5 groups. There were no serious side effects, including a plasma concentration increase of lidocaine, attributable to the SRLS. Conclusions Administration of the SRLS at 100 mg may have clinical therapeutic potential for pain relief following tooth extraction. The safety of the SRLS for patients undergoing tooth extraction was demonstrated. Trial registration The University Hospital Medical Information Network UMIN000011945
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Affiliation(s)
- Toshiyuki Suzuki
- Department of Anesthesiology, Gunma University Graduate School of Medicine, Maebashi-shi, Gunma, Japan
- * E-mail:
| | - Kensuke Kosugi
- Department of Oral and Maxillofacial Surgery, Gunma University Graduate School of Medicine, Maebashi-shi, Gunma, Japan
| | - Takashi Suto
- Department of Anesthesiology, Gunma University Graduate School of Medicine, Maebashi-shi, Gunma, Japan
| | - Masaru Tobe
- Department of Anesthesiology, Gunma University Graduate School of Medicine, Maebashi-shi, Gunma, Japan
| | - Yasuhiko Tabata
- Department of Biomaterials, Field of Tissue Engineering, Institute for Frontier Medical Sciences, Kyoto University, Kyoto-shi, Kyoto, Japan
| | - Satoshi Yokoo
- Department of Oral and Maxillofacial Surgery, Gunma University Graduate School of Medicine, Maebashi-shi, Gunma, Japan
| | - Shigeru Saito
- Department of Anesthesiology, Gunma University Graduate School of Medicine, Maebashi-shi, Gunma, Japan
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Connolly NC. Real-world insights on the use of transversus abdominis plane block with liposomal bupivacaine in the multimodal management of somatic versus visceral pain in the colorectal surgery setting. J Pain Res 2018; 11:1141-1146. [PMID: 29942149 PMCID: PMC6007189 DOI: 10.2147/jpr.s168817] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
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Tobe M, Suto T, Saito S. The history and progress of local anesthesia: multiple approaches to elongate the action. J Anesth 2018; 32:632-636. [PMID: 29855722 DOI: 10.1007/s00540-018-2514-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Accepted: 05/23/2018] [Indexed: 12/18/2022]
Abstract
Analgesia and temporary inhibition of motor activity without interfering with central nervous function have been the essential merits of local anesthesia. Local anesthetics originated from cocaine have played a major role in local analgesia. However, the relatively short duration of action of local anesthetics has been a concern in intra- and post-operative analgesia. From the early age of modern local anesthesia, physicians and medical scientists had been struggling to control the active duration of local anesthetics. Such approach includes: development of long-acting local anesthetics, with physical tourniquet techniques, co-administration of other medicines such as vaso-constrictive agents or analgesics, development of mechanical devices to continuously or intermittently administer local anesthetics, and utilization of pharmaceutical drug delivery systems. In this review, the historical sequence of studies that have been performed in an effort to elongate the action of local anesthetics is presented, referring to epoch-making medical and scientific studies.
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Affiliation(s)
- Masaru Tobe
- Department of Anesthesiology, Gunma University Graduate School of Medicine, 3-39-22, Showa, Maebashi, Gunma, 371-8511, Japan.
| | - Takashi Suto
- Department of Anesthesiology, Gunma University Graduate School of Medicine, 3-39-22, Showa, Maebashi, Gunma, 371-8511, Japan
| | - Shigeru Saito
- Department of Anesthesiology, Gunma University Graduate School of Medicine, 3-39-22, Showa, Maebashi, Gunma, 371-8511, Japan
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Extended Release Liposomal Bupivacaine Injection (Exparel) for Early Postoperative Pain Control Following Pharyngoplasty. J Craniofac Surg 2018; 29:726-730. [DOI: 10.1097/scs.0000000000004312] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Wilsey JT, Block JH. Sustained analgesic effect of clonidine co-polymer depot in a porcine incisional pain model. J Pain Res 2018; 11:693-701. [PMID: 29670396 PMCID: PMC5898591 DOI: 10.2147/jpr.s157018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Previous research suggests that the α2 adrenergic agonist clonidine, a centrally acting analgesic and antihypertensive, may also have direct effects on peripheral pain generators. However, aqueous injections are limited by rapid systemic absorption leading to off target effects and a brief analgesic duration of action. Purpose The aim of this study was to examine the efficacy of a sustained-release clonidine depot, placed in the wound bed, in a pig incisional pain model. Methods The depot was a 15 mm ×5 mm ×0.3 mm poly(lactide-co-caprolactone) polymer film containing 3% (w/w) clonidine HCl (MDT3). Fifty-two young adult mix Landrace pigs (9–11 kg) were divided into seven groups. All subjects received a 6 cm, full-thickness, linear incision into the left lateral flank. Group 1 served as a Sham control group (Sham, n=8). Group 2 received three placebo strips (PBO, n=8), placed end-to-end in the subcutaneous wound bed before wound closure. Group 3 received one MDT3 and two PBO (n=8), Group 4 received two MDT3 and one PBO (n=8), and Group 5 received three MDT3 (n=8). Positive control groups received peri-incisional injections of bupivacaine solution (Group 6, 30 mg/day bupivacaine, n=8) or clonidine solution (Group 7, 225 µg/day, n=4). Results The surgical procedure was associated with significant peri-incisional tactile allodynia. There was a dose-dependent effect of MDT3 in partially reversing the peri-incisional tactile allodynia, with maximum pain relief relative to Sham at 72 hours. Daily injections of bupivacaine (30 mg), but not clonidine (up to 225 µg), completely reversed allodynia within 48 hours. There was a statistically significant correlation between the dose of MDT3 and cumulative withdrawal threshold from 4 hours through the conclusion of the study on day 7. Conclusion These data suggest that a sustained-release clonidine depot may be a viable nonopioid, nonamide anesthetic therapy for the treatment of acute postsurgical nociceptive sensitization.
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Gottlieb IJ, Tunick DR, Mack RJ, McCallum SW, Howard CP, Freyer A, Du W. Evaluation of the safety and efficacy of an intravenous nanocrystal formulation of meloxicam in the management of moderate-to-severe pain after bunionectomy. J Pain Res 2018; 11:383-393. [PMID: 29497329 PMCID: PMC5819580 DOI: 10.2147/jpr.s149879] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Objective This randomized, double-blind, placebo-controlled study evaluated the safety and efficacy of an intravenous (IV) nanocrystal formulation of meloxicam in subjects with moderate-to-severe pain following a standardized unilateral bunionectomy. Methods Fifty-nine subjects aged 18–72 years were randomized to receive doses of either 30 mg (n=20) or 60 mg (n=20) meloxicam IV or placebo (n=19), administered once daily as bolus IV injections over 15–30 seconds (two or three doses). Safety, the primary objective, was assessed by physical examination, clinical laboratory tests, and the incidence of adverse events (AEs). Efficacy was evaluated by examining summed pain intensity differences over the first 48 hours (SPID48) using analysis of covariance models. Use of opioid rescue analgesic agents was evaluated. Results Generally, AEs were mild-to-moderate in intensity, and their incidence was similar across the three treatment groups. No serious AEs were reported; there were no withdrawals due to AEs, including injection-related AEs. The estimated effect size for SPID48 versus placebo was 1.15 and 1.01 for meloxicam IV doses 30 mg and 60 mg, respectively (P≤0.01). Both doses produced significantly greater pain reductions versus placebo (P≤0.05) at all evaluated times/ intervals during the 48-hour period. The proportions of subjects with ≥30% and ≥50% overall reduction in pain from baseline after 6 and 24 hours were significantly higher with meloxicam IV 30 mg doses versus placebo, but not with meloxicam IV 60 mg doses. The time to first use of rescue medication was significantly longer versus placebo with meloxicam IV 60 mg (P<0.05), but not with meloxicam IV 30 mg doses. Conclusion Meloxicam IV was generally safe and well tolerated in subjects with moderate-to-severe post-bunionectomy pain. Once-daily administration of meloxicam IV 30 mg and 60 mg exhibited rapid onset of analgesia (as early as 15 minutes) with maintenance of analgesic effect for two consecutive 24-hour periods.
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Affiliation(s)
| | | | | | | | - Campbell P Howard
- Howard Medical Consulting for the Pharmaceutical Industry, Yardley, PA, USA
| | | | - Wei Du
- Clinical Statistics Consulting, Blue Bell, PA, USA
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Braito M, Dammerer D, Schlager A, Wansch J, Linhart C, Biedermann R. Continuous Wound Infiltration After Hallux Valgus Surgery. Foot Ankle Int 2018; 39:180-188. [PMID: 29073780 DOI: 10.1177/1071100717736292] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Hallux valgus surgery is associated with significant early postoperative pain. The aim of this study was to investigate the use of continuous wound infiltration (CWI) with ropivacaine for pain management after hallux valgus surgery. METHODS In this prospective, randomized, double-blind, and placebo-controlled single-center trial, 50 patients undergoing distal metatarsal osteotomy for idiopathic hallux valgus were allocated to CWI with ropivacaine 2 mg/mL at a rate of 2 mL/h or placebo for 24 hours postoperatively. Average and peak pain levels on the verbal numeric rating scale (NRS; 1-10) during the first 48 hours after surgery were recorded as primary outcome parameters. Secondary outcome parameters included consumption of narcotics, clinical outcome, incidence of postoperative complications, and patient satisfaction. RESULTS No significant difference in mean ( P = .596) and peak ( P = .353) postoperative pain level was found for CWI with either ropivacaine (mean NRS 1.9 ± 0.8; peak NRS 3.5 ± 2.0) or placebo (mean NRS 2.0 ± 0.7; peak NRS 3.9 ± 1.7) during the early postoperative course. Furthermore, no significant difference between both groups was detected regarding narcotic consumption ( P = .354) and all other secondary outcome parameters. Two severe complications (local dysesthesia with CWI, catheter accidentally fixed by a suture) and 5 catheter dislocations were observed. CONCLUSION CWI with ropivacaine 2 mg/mL at a rate of 2 mL/h for 24 hours after hallux valgus surgery did not reduce postoperative pain level in an inpatient setting. LEVEL OF EVIDENCE Level I, prospective randomized trial.
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Affiliation(s)
- Matthias Braito
- 1 Department of Orthopedic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Dietmar Dammerer
- 1 Department of Orthopedic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Andreas Schlager
- 2 Department of Anesthesiology and Critical Care, Medical University of Innsbruck, Innsbruck, Austria
| | - Jürgen Wansch
- 1 Department of Orthopedic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Caroline Linhart
- 3 Department of Medical Statistics, Medical University of Innsbruck, Innsbruck, Austria
| | - Rainer Biedermann
- 1 Department of Orthopedic Surgery, Medical University of Innsbruck, Innsbruck, Austria
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85
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Alter TH, Liss FE, Ilyas AM. A Prospective Randomized Study Comparing Bupivacaine Hydrochloride Versus Bupivacaine Liposome for Pain Management After Distal Radius Fracture Repair Surgery. J Hand Surg Am 2017; 42:1003-1008. [PMID: 28969978 DOI: 10.1016/j.jhsa.2017.08.022] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Revised: 07/28/2017] [Accepted: 08/22/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare pain experience and opioid use after distal radius fracture repair surgery performed with perioperative infiltration of the local anesthesia bupivacaine hydrochloride (Marcaine; Pfizer, New York, NY) or bupivacaine liposome (Exparel; Pacira, Parsippany, NJ). METHODS We conducted a prospective comparison of consecutive patients scheduled to undergo distal radius fracture repair surgery. Patients were randomized to either Marcaine or Exparel. Patients in the Marcaine group received 20 mL 0.5% bupivacaine without epinephrine into the incision and surgical site before incision. Patients in the Exparel group first received 10 mL 0.5% Marcaine with no epinephrine into the incision and surgical site before incision; then, upon completion of the surgery and wound closure, they also received 10 mL Exparel into the same site that had been preinjected with Marcaine. All operations were performed with the same surgical technique. Daily opioid pill consumption, pain levels, and any adverse reactions were recorded from postoperative days 0 to 5. RESULTS On the day of surgery, patients in the Exparel group reported significantly lower pain levels (3.9 vs 5.8) and consumed significantly fewer prescribed opioid pills (1.2 vs 2.0) compared with patients in the Marcaine group. However, there were no other significant differences between the Exparel and Marcaine groups on any subsequent days or in the total number of pills consumed at the end of the study period (7.5 vs 8.9 pills, respectively). No major adverse reactions were noted in either group. CONCLUSIONS Exparel use was found to result in decreased pain and opioid consumption only on the day of surgery and not thereafter. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic II.
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Affiliation(s)
- Todd H Alter
- Rothman Institute at Thomas Jefferson University, Philadelphia, PA
| | - Frederic E Liss
- Rothman Institute at Thomas Jefferson University, Philadelphia, PA
| | - Asif M Ilyas
- Rothman Institute at Thomas Jefferson University, Philadelphia, PA.
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87
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Mulligan RP, Morash JG, DeOrio JK, Parekh SG. Liposomal Bupivacaine Versus Continuous Popliteal Sciatic Nerve Block in Total Ankle Arthroplasty. Foot Ankle Int 2017; 38:1222-1228. [PMID: 28786304 DOI: 10.1177/1071100717722366] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Liposomal bupivacaine (LB) is widely used in joint arthroplasty, but there is little reported on the use of LB in foot and ankle surgery. Continuous popliteal sciatic nerve block (CPSNB) is more commonly used for major foot and ankle reconstructions. The purpose of this study was to compare use of intraoperative LB injection to CPSNB as a regional anesthetic for total ankle arthroplasty (TAA), with attention to postoperative pain scores, narcotic use, and complications. METHODS Retrospective review of TAA patients of 2 fellowship-trained orthopedic foot and ankle surgeons was performed. Patients received either preoperative single-shot popliteal sciatic nerve block with 0.2% ropivacaine followed by intraoperative injection of LB or preoperative CPSNB alone. Outcomes examined were visual analog scale (VAS) pain score at 8 hours, 24 hours, 1 week, and 3 weeks following surgery; need for opioid pain medication refill; physician office notification for pain issues or other adverse events; and complications within the first 90 days following surgery. Standard statistical analysis was performed, and P < .05 was considered significant. Seventy-five patients were identified who underwent TAA and met inclusion criteria. Forty-one received LB, and 34 received CPSNB. RESULTS No statistical difference was seen between groups with regard to complications, emergency department visits, readmissions, reoperations, VAS pain score at any time point, physician office contacts, and narcotic refills. Sixteen of 41 (39%) LB patients had narcotic refills, versus 12 of 34 (35%) CPSNB patients ( P = .81). Two of 41 (5%) LB patients had a complication postoperatively, versus 4 of 34 (12%) CPSNB patients. There were no complications specific to the anesthetic used in either group. CONCLUSION This is the first study evaluating the use of LB for total ankle arthroplasty. Liposomal bupivacaine was safe and effective as an option for regional anesthetic and postoperative pain control, with comparable results to CPSNB. LEVEL OF EVIDENCE Level III, retrospective comparative study.
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Affiliation(s)
- Ryan P Mulligan
- 1 Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Joel G Morash
- 2 Department of Orthopaedic Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - James K DeOrio
- 1 Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Selene G Parekh
- 1 Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA.,3 Duke Fuqua School of Business, Durham, NC, USA
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Weller WJ, Azzam MG, Smith RA, Azar FM, Throckmorton TW. Liposomal Bupivacaine Mixture Has Similar Pain Relief and Significantly Fewer Complications at Less Cost Compared to Indwelling Interscalene Catheter in Total Shoulder Arthroplasty. J Arthroplasty 2017; 32:3557-3562. [PMID: 28390888 DOI: 10.1016/j.arth.2017.03.017] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Revised: 02/20/2017] [Accepted: 03/07/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The efficacy and costs of indwelling interscalene catheter (ISC) and liposomal bupivacaine (LBC), with and without adjunctive medications, in patients with primary shoulder arthroplasty are a source of current debate. METHODS In 214 arthroplasties, 156 patients had ISC and 58 had LBC injections that were mixed with morphine, ketorolac, and 0.5% bupivacaine with epinephrine. Charts were reviewed for visual analog scale pain scores, oral morphine equivalent (OME) usage, major complications, and costs. RESULTS Visual analog scale scores were not significantly different at 24 hours or at 2, 6, and 12 weeks. Average OME consumption at 24 hours was significantly more with LBC, but was not significantly different at 12 weeks. Relative risk of a major complication was nearly 4 times higher with ISC than with LBC. The average cost for the LBC mixture was $289.04, and for ISC, including equipment and anesthesia fees, was $1559.42. CONCLUSION The intraoperative LBC mixture provided equivalent pain relief with significantly fewer major complications and at markedly lower cost than ISC. LBC required almost twice as much OME to attain the same level of pain relief at 24 hours, but there was no significant difference in the cumulative amount of outpatient narcotic use.
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Affiliation(s)
- William J Weller
- Department of Orthopaedic Surgery & Biomedical Engineering, University of Tennessee-Campbell Clinic, Memphis, Tennessee
| | - Michael G Azzam
- Department of Orthopaedic Surgery & Biomedical Engineering, University of Tennessee-Campbell Clinic, Memphis, Tennessee
| | - Richard A Smith
- Department of Orthopaedic Surgery & Biomedical Engineering, University of Tennessee-Campbell Clinic, Memphis, Tennessee
| | - Frederick M Azar
- Department of Orthopaedic Surgery & Biomedical Engineering, University of Tennessee-Campbell Clinic, Memphis, Tennessee
| | - Thomas W Throckmorton
- Department of Orthopaedic Surgery & Biomedical Engineering, University of Tennessee-Campbell Clinic, Memphis, Tennessee
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Mazloomdoost D, Pauls RN, Hennen EN, Yeung JY, Smith BC, Kleeman SD, Crisp CC. Liposomal bupivacaine decreases pain following retropubic sling placement: a randomized placebo-controlled trial. Am J Obstet Gynecol 2017; 217:598.e1-598.e11. [PMID: 28694151 DOI: 10.1016/j.ajog.2017.07.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Revised: 06/09/2017] [Accepted: 07/01/2017] [Indexed: 11/27/2022]
Abstract
BACKGROUND Midurethral slings are commonly used to treat stress urinary incontinence. Pain control, however, may be a concern. Liposomal bupivacaine is a local anesthetic with slow release over 72 hours, demonstrated to lower pain scores and decrease narcotic use postoperatively. OBJECTIVE The purpose of this study was to examine the impact of liposomal bupivacaine on pain scores and narcotic consumption following retropubic midurethral sling placement. STUDY DESIGN This randomized, placebo-controlled trial enrolled women undergoing retropubic midurethral sling procedures with or without concomitant anterior or urethrocele repair. Subjects were allocated to receive liposomal bupivacaine (intervention) or normal saline placebo injected into the trocar paths and vaginal incision at the conclusion of the procedure. At the time of drug administration, surgeons became unblinded, but did not collect outcome data. Participants remained blinded to treatment. Surgical procedures and perioperative care were standardized. The primary outcome was the visual analog scale pain score 4 hours after discharge home. Secondary outcomes included narcotic consumption, time to first bowel movement, and pain scores collected in the mornings and evenings until postoperative day 6. The morning pain item assessed "current level of pain"; the evening items queried "current level of pain," "most intense pain today," "average pain today with activity," and "average pain today with rest." Likert scales were used to measure satisfaction with pain control at 1- and 2-week postoperative intervals. Sample size calculation deemed 52 subjects per arm necessary to detect a mean difference of 10 mm on a 100-mm visual analog scale. To account for 10% drop out, 114 participants were needed. RESULTS One hundred fourteen women were enrolled. After 5 exclusions, 109 cases were analyzed: 54 women received intervention, and 55 women received placebo. Mean participant age was 52 years, and mean body mass index was 30.4 kg/m2. Surgical and demographic characteristics were similar, except for a slightly higher body mass index in the placebo group (31.6 vs 29.2 kg/m2; P=.050), and fewer placebo arm subjects received midazolam during anesthesia induction (44 vs 52; P=.015). For the primary outcome, pain score (millimeter) 4 hours after discharge home was lower in the intervention group (3.5 vs 13.0 millimeters; P=.014). Pain scores were also lower for subjects receiving liposomal bupivacaine at other time points collected during the first three postoperative days. Furthermore, fewer subjects in the intervention group consumed narcotic medication on postoperative day 2 (12 vs 27; P=.006). There was no difference in satisfaction with pain control between groups. Side-effects experienced, rate of postoperative urinary retention, and time to first bowel movement were similar between groups. Finally, no serious adverse events were noted. CONCLUSION Liposomal bupivacaine decreased postoperative pain scores following retropubic midurethral sling placement, though pain was low in both the intervention and placebo groups. Participants who received liposomal bupivacaine were less likely to use narcotics on postoperative day 2. For this common outpatient surgery, liposomal bupivacaine may be a beneficial addition. Given the cost of this intervention, however, future cost-effective analyses may be useful.
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A prospective randomized controlled trial to identify the optimal postoperative pain management in shoulder arthroplasty: liposomal bupivacaine versus continuous interscalene catheter. J Shoulder Elbow Surg 2017; 26:1810-1817. [PMID: 28844420 DOI: 10.1016/j.jse.2017.06.044] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 06/13/2017] [Accepted: 06/19/2017] [Indexed: 02/01/2023]
Abstract
BACKGROUND Shoulder arthroplasty is the fastest growing joint replacement surgery in the United States, and optimal postoperative pain management is critical to optimize outcomes for these surgeries. Liposomal bupivacaine (LB) has gained popularity for its potential to provide extended postoperative pain relief with possibly fewer side effects. The goal of this study was to assess the impact of LB compared with continuous interscalene nerve block (CISB) in terms of postoperative pain control, outpatient pain scores, and patient-reported and functional outcomes after shoulder arthroplasty surgery. METHODS A prospective randomized controlled clinical trial compared consecutive patients undergoing shoulder arthroplasty treated with CISB vs. LB with a single bolus interscalene block. The primary outcome measures included pain assessment up to 24 hours after surgery; in addition, all doses and times of narcotics administered during the inpatient stay were recorded. Patient-reported outcome measures for pain, satisfaction, and functional outcomes were recorded postoperatively. RESULTS A total of 70 of 74 consecutive patients who underwent shoulder arthroplasty were included in the study. The LB group had equivalent narcotic use, pain scores, and time to first narcotic rescue compared with the CISB group within the first 24 hours (P > .05). The LB group had higher American Shoulder and Elbow Surgeons score and Penn Shoulder Score at final follow-up. There was an increased number of complications and cost for the CISB group. CONCLUSION This prospective randomized controlled trial demonstrated that LB provides excellent postoperative pain relief for shoulder arthroplasty patients. In addition, LB had fewer complications and lower cost, making it a promising addition to a multimodal pain regimen for shoulder arthroplasty.
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Abstract
Progress in surgical acute pain management has allowed most foot and ankle surgery to be performed in ambulatory outpatient surgical centers. Multimodal analgesia focuses on improving postoperative pain by combining pharmacologic and other modalities, addressing multiple pain mechanisms and receptor pathways while reducing adverse effects through lower doses of oral medications. Local anesthesia techniques provide excellent pain relief with few adverse events. Multimodal analgesia in foot and ankle surgery provides superior pain relief, and reduced opioid dependence and opioid-related side effects, improving patient satisfaction, safety, and timely return to function.
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Affiliation(s)
- Jessica M Kohring
- Department of Orthopaedics, The University of Utah, 590 Wakara Way, Salt Lake City, UT 84108, USA.
| | - Nathan G Orgain
- Department of Anesthesiology, The University of Utah, SOM 3C444, 30 North 1900 East, Salt Lake City, UT 84132, USA
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DeClaire JH, Aiello PM, Warritay OK, Freeman DC. Effectiveness of Bupivacaine Liposome Injectable Suspension for Postoperative Pain Control in Total Knee Arthroplasty: A Prospective, Randomized, Double Blind, Controlled Study. J Arthroplasty 2017; 32:S268-S271. [PMID: 28478185 DOI: 10.1016/j.arth.2017.03.062] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Revised: 03/06/2017] [Accepted: 03/26/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND We compared the effectiveness of liposomal bupivacaine to ropivacaine, each as part of multimodal pain management, in total knee arthroplasty (TKA) postoperative pain control. METHODS This prospective, double blind study randomized 96 TKA patients into a control group (periarticular injection of ropivacaine, ketorolac, morphine, and epinephrine in saline; 100cc) or an experimental group (periarticular injection of bupivacaine, ketorolac, morphine, and epinephrine in saline; 80cc plus 1.3% liposomal bupivacaine 20cc; total injection 100cc). The postoperative use of narcotics, visual analog pain scores, hours to ambulate 100 feet, and length of hospital stay were recorded. RESULTS There was no significant difference between the two groups (control N = 49, experiment N = 47) in mean narcotic use per hour, total narcotic use during hospital stay, time to ambulate 100 feet, length of hospital stay, or visual analog score for pain postoperatively. CONCLUSION There is no benefit in the use of liposomal bupivacaine compared with ropivacaine for postoperative pain control in TKA.
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Affiliation(s)
- Jeffrey H DeClaire
- Department of Surgery and Orthopaedic Surgery, DeClaire LaMacchia Orthopaedic Institute, Crittenton Hospital Medical Center, Rochester Hills, Michigan
| | - Paige M Aiello
- Wayne State University School of Medicine, Detroit, Michigan
| | - Olayinka K Warritay
- Department of Family Medicine and Public Health Services, Wayne State University School of Medicine Family Medicine Residency Program at Crittenton Hospital, Rochester Hills, Michigan
| | - Dwight C Freeman
- Department of Biological Sciences, Wayne State University, Detroit, Michigan
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Angerame MR, Ruder JA, Odum SM, Hamid N. Pain and Opioid Use After Total Shoulder Arthroplasty With Injectable Liposomal Bupivacaine Versus Interscalene Block. Orthopedics 2017; 40:e806-e811. [PMID: 28617519 DOI: 10.3928/01477447-20170608-01] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Accepted: 04/24/2017] [Indexed: 02/03/2023]
Abstract
Postoperative pain control is a significant concern after total shoulder arthroplasty. Injectable periarticular liposomal bupivacaine, which has been found to decrease opioid use after orthopedic procedures, has been proposed as a viable alternative to regional anesthesia. This study compared the efficacy of liposomal bupivacaine vs interscalene block among patients undergoing total shoulder arthroplasty. A retrospective review was conducted of 79 patients who underwent anatomic total shoulder arthroplasty performed by a single surgeon between January 2013 and April 2015. Patient demographics, in-hospital Numeric Pain Rating Scale (NPRS) score obtained at 12-hour intervals, length of stay, and total in-hospital morphine equivalents in both the bupivacaine (n=25) and block (n=44) groups were recorded. Differences in length of stay, morphine equivalents, and age were assessed with Wilcoxon tests. Sex differences were assessed with the chi-square test. Repeated measures analysis with least square means was used to assess longitudinal changes in NPRS scores. No significant differences were found between groups for sex (P=.89), age (P=.81), American Society of Anesthesiologists classification (P=.50), preoperative opioid use (P=.41), length of stay (P=.32), or morphine equivalents (P=.71). The average NPRS score in the first 12 hours was 3.01 for the bupivacaine group and 4.41 for the interscalene block group (P=.25). By 48 hours postoperatively, average NPRS scores were similar (P=.93) for the 2 groups, 4.90 for the bupivacaine group and 4.19 for the interscalene block group. The findings for this cohort of patients undergoing anatomic total shoulder arthroplasty showed no significant difference for pain scores, postoperative narcotic use, or length of stay with injectable liposomal bupivacaine vs interscalene block. [Orthopedics. 2017; 40(5):e806-e811.].
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Smith EB, Kazarian GS, Maltenfort MG, Lonner JH, Sharkey PF, Good RP. Periarticular Liposomal Bupivacaine Injection Versus Intra-Articular Bupivacaine Infusion Catheter for Analgesia After Total Knee Arthroplasty: A Double-Blinded, Randomized Controlled Trial. J Bone Joint Surg Am 2017; 99:1337-1344. [PMID: 28816893 DOI: 10.2106/jbjs.16.00571] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Intra-articular bupivacaine hydrochloride (HCl) infusion catheters and periarticular injections of liposomal bupivacaine are often used as postoperative local anesthetics. The purpose of this study was to compare the efficacies of these local anesthetics following total knee arthroplasty. METHODS This study was a superiority trial with a randomized, controlled, double-blinded design. Patients were randomly assigned to either delivery of bupivacaine HCl by the ON-Q* Pain Relief System pump (n = 96) or by an injection of Exparel (liposomal bupivacaine) (n = 104). The primary outcome of this study was cumulative narcotic consumption on postoperative days 0 through 3. Narcotic consumption data were collected retrospectively from in-hospital records while patients were in the hospital. Following discharge, narcotic consumption data were gathered from patient surveys, as were secondary outcomes measures. RESULTS We did not identify greater narcotic use in the ON-Q* group compared with the Exparel group (p = 0.641). The mean difference between the groups was 0.5 morphine equivalent (95% confidence interval [CI] = -1.7 to +2.8), with the ON-Q* group consuming an average 10.4 morphine equivalents (95% CI = 8.7 to 12.0) compared with 10.9 (95% CI = 9.3 to 12.5) in the Exparel group. There were no significant differences between groups with regard to any of the secondary measures of pain with the exception of pain while walking and pain with physical therapy (p = 0.019 and p = 0.010, respectively), both of which showed an approximately 1-point difference in favor of the ON-Q* group on a visual analog scale (VAS). There were also no differences in the postoperative side effects, including nausea, constipation, or vomiting, or in the rates of study-related complications, patient satisfaction, or length of hospital stay. CONCLUSIONS Exparel did not have superior efficacy compared with the ON-Q* Pain Relief System as reflected by narcotic consumption, our primary outcome. There were small significant differences, in favor of the ON-Q* group, in 2 secondary measures of pain during activity, but these approximately 1-point VAS differences are unlikely to be clinically relevant. The choice of a local anesthetic modality should be based on a combination of safety, convenience, and cost considerations. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Eric B Smith
- 1The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
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The Use of Liposomal Bupivacaine Administered With Standard Bupivacaine in Ankle Fractures Requiring Open Reduction Internal Fixation: A Single-Blinded Randomized Controlled Trial. J Orthop Trauma 2017; 31:434-439. [PMID: 28430722 DOI: 10.1097/bot.0000000000000862] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To determine the efficacy of liposomal bupivacaine compared to placebo for postoperative pain control in patients undergoing operative fixation of ankle fractures. DESIGN Prospective single-blinded randomized control trial. SETTING Academic Medical Center. PATIENTS/PARTICIPANTS After Institutional Review Board (IRB) approval, 76 patients who sustained an acute ankle fracture (OTA/AO 44A-C) requiring operative fixation met inclusion criteria. INTERVENTION Patients were randomly assigned to 1 of 2 groups, control (local intraoperative sterile saline injection under general anesthesia) or interventional (local intraoperative liposomal bupivacaine and bupivacaine injection under general anesthesia). Injections were administered in a standardized fashion and included injection of a 1:1 mixture of a 40 mL solution consisting of 1.3% Exparel and sterile saline (interventional) or a 40 mL injection of normal saline (control) into the surrounding periosteal, peritendinous, surrounding muscles and subcutaneous tissue of the surgical incision(s). MAIN OUTCOME MEASUREMENTS Pain medications administered and pain according to the Visual Analogue Scale was recorded at scheduled postoperative time points: 4, 24, 48, 72, and 336 hours (14 days). RESULTS Thirty-nine patients were randomized to the control group and 37 to the interventional group (mean age = 42 ± 15 years), with no statistically significant differences between groups with regards to severity of injury and patient demographics. Pain scores were significantly lower in the interventional group versus control up to 2 weeks after surgery. Percocet ingestion at 4 hours was significantly lower in the interventional group (0.7 vs. 1.3, P = 0.004), while it approached significance at 48 hours postoperatively (2.8 vs. 3.69, P = 0.07). No other significant differences were noted for Percocet ingestion postoperatively at other time points assessed. The overall satisfaction with pain control was not statistically different between the 2 groups (P = 0.93). CONCLUSION Local intraoperative infiltration of liposomal bupivacaine administered with standard bupivacaine for ankle fractures requiring Open Reduction Internal Fixation (ORIF) affords improved pain relief in the immediate postoperative period resulting in a reduction in Percocet ingestion, with resultant effects seen up to 2 days postoperatively. Continued investigation of this drug for use with extremity fractures is warranted. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
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Transversus Abdominis Plane Blocks with Single-Dose Liposomal Bupivacaine in Conjunction with a Nonnarcotic Pain Regimen Help Reduce Length of Stay following Abdominally Based Microsurgical Breast Reconstruction. Plast Reconstr Surg 2017; 140:240-251. [DOI: 10.1097/prs.0000000000003508] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Reinstatler L, Shee K, Gross MS. Pain Management in Penile Prosthetic Surgery: A Review of the Literature. Sex Med Rev 2017; 6:162-169. [PMID: 28735683 DOI: 10.1016/j.sxmr.2017.05.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2017] [Accepted: 05/15/2017] [Indexed: 02/03/2023]
Abstract
INTRODUCTION The literature on perioperative pain control and management in inflatable penile prosthesis placement is not firmly established. Because inflatable penile prosthesis placement is an elective procedure, pain can be one of the many issues that influence patient decision making. Pain control also presents a unique challenge to providers in an era of widespread opiate abuse. AIM To review published data on pain management before, during, and after penile prosthetic surgery. METHODS Peer-reviewed literature and conference abstracts were analyzed for all relevant publications related to this issue. RESULTS The past several decades have seen a shift from general to local anesthesia for penile prosthetic surgery. This has been well characterized and is seen as successful with different local anesthetic options and techniques. To date, only one study has provided follow-up for longer than 1 week regarding postoperative pain management for prosthetic surgery. CONCLUSION Perioperative pain management for the patient receiving a penile prosthetic is well characterized; postoperative pain management is not. Although periprocedural local anesthesia has been well described for penile prosthesis surgery, a standardized postoperative pain management plan does not exist. This review highlights the need for further characterization of postoperative pain and the subsequent development of an algorithmic approach for management. Reinstatler L, Shee K, Gross MS. Pain Management in Penile Prosthetic Surgery: A Review of the Literature. Sex Med Rev 2018;6:162-169.
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Affiliation(s)
| | - Kevin Shee
- Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
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Singla NK, Meske DS, Desjardins PJ. Exploring the Interplay between Rescue Drugs, Data Imputation, and Study Outcomes: Conceptual Review and Qualitative Analysis of an Acute Pain Data Set. Pain Ther 2017; 6:165-175. [PMID: 28676997 PMCID: PMC5693805 DOI: 10.1007/s40122-017-0074-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Indexed: 11/01/2022] Open
Abstract
In placebo-controlled acute surgical pain studies, provisions must be made for study subjects to receive adequate analgesic therapy. As such, most protocols allow study subjects to receive a pre-specified regimen of open-label analgesic drugs (rescue drugs) as needed. The selection of an appropriate rescue regimen is a critical experimental design choice. We hypothesized that a rescue regimen that is too liberal could lead to all study arms receiving similar levels of pain relief (thereby confounding experimental results), while a regimen that is too stringent could lead to a high subject dropout rate (giving rise to a preponderance of missing data). Despite the importance of rescue regimen as a study design feature, there exist no published review articles or meta-analysis focusing on the impact of rescue therapy on experimental outcomes. Therefore, when selecting a rescue regimen, researchers must rely on clinical factors (what analgesics do patients usually receive in similar surgical scenarios) and/or anecdotal evidence. In the following article, we attempt to bridge this gap by reviewing and discussing the experimental impacts of rescue therapy on a common acute surgical pain population: first metatarsal bunionectomy. The function of this analysis is to (1) create a framework for discussion and future exploration of rescue as a methodological study design feature, (2) discuss the interplay between data imputation techniques and rescue drugs, and (3) inform the readership regarding the impact of data imputation techniques on the validity of study conclusions. Our findings indicate that liberal rescue may degrade assay sensitivity, while stringent rescue may lead to unacceptably high dropout rates.
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Affiliation(s)
- Neil K Singla
- Lotus Clinical Research, Huntington Hospital, Department of Anesthesiology, Pasadena, CA, USA.
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Abildgaard JT, Lonergan KT, Tolan SJ, Kissenberth MJ, Hawkins RJ, Washburn R, Adams KJ, Long CD, Shealy EC, Motley JR, Tokish JM. Liposomal bupivacaine versus indwelling interscalene nerve block for postoperative pain control in shoulder arthroplasty: a prospective randomized controlled trial. J Shoulder Elbow Surg 2017; 26:1175-1181. [PMID: 28479257 DOI: 10.1016/j.jse.2017.03.012] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Revised: 02/24/2017] [Accepted: 03/01/2017] [Indexed: 02/01/2023]
Abstract
BACKGROUND Pain management strategies following shoulder arthroplasty vary significantly. Liposomal bupivacaine (LB) is an extended-release delivery of a phospholipid bilayer encapsulating bupivacaine that can result in drug delivery up to 72 hours. Prior studies in lower extremity surgery demonstrated efficacy of LB in comparison to a single-shot peripheral nerve block; however, no study has investigated LB in a total shoulder arthroplasty population. Therefore, this study compared LB vs. an indwelling interscalene nerve block (IINB). METHODS This is a prospective, randomized study of 83 consecutive shoulder arthroplasty patients; 36 patients received LB and a "bridge" of 30 mL of 0.5% bupivacaine, and 47 patients received an IINB. Postoperative visual analog scale pain levels, opiate consumption measured with oral morphine equivalents, length of hospital stay, and postoperative complications were recorded. Continuous variables were compared using an analysis of variance with significance set at P < .05. RESULTS Visual analog scale pain scores were statistically higher in the LB cohort immediately postoperatively in the postanesthesia care unit (7.25 vs. 1.91; P = .000) as well as for the remainder of postoperative day 0 (4.99 vs. 3.20; P = .005) but not for the remainder of admission. Opiate consumption was significantly higher among the LB cohort in the postanesthesia care unit (31.79 vs. 7.47; P = .000), on postoperative day 0 (32.64 vs. 15.04; P = .000), and for the total hospital admission (189.50 vs. 91.70, P = .000). Complication numbers and length of stay were not statistically different. CONCLUSION Use of an IINB provides superior pain management in the immediate postoperative setting as demonstrated by decreased narcotic medication consumption and lower subjective pain scores.
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Affiliation(s)
- Jeffrey T Abildgaard
- Steadman Hawkins Clinic of the Carolinas, Greenville Health System, Greenville, SC, USA
| | - Keith T Lonergan
- Steadman Hawkins Clinic of the Carolinas, Greenville Health System, Greenville, SC, USA
| | - Stefan J Tolan
- Steadman Hawkins Clinic of the Carolinas, Greenville Health System, Greenville, SC, USA
| | - Michael J Kissenberth
- Steadman Hawkins Clinic of the Carolinas, Greenville Health System, Greenville, SC, USA
| | - Richard J Hawkins
- Steadman Hawkins Clinic of the Carolinas, Greenville Health System, Greenville, SC, USA
| | - Richard Washburn
- Steadman Hawkins Clinic of the Carolinas, Greenville Health System, Greenville, SC, USA
| | | | | | | | - Jay R Motley
- Department of Anesthesiology, Greenville Health System, Greenville, SC, USA
| | - John M Tokish
- Steadman Hawkins Clinic of the Carolinas, Greenville Health System, Greenville, SC, USA.
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Tan P, Martin M, Shank N, Myers L, Wolfe E, Lindsey J, Metzinger S. A Comparison of 4 Analgesic Regimens for Acute Postoperative Pain Control in Breast Augmentation Patients. Ann Plast Surg 2017; 78:S299-S304. [PMID: 28459704 PMCID: PMC6686898 DOI: 10.1097/sap.0000000000001132] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE Patients undergoing breast augmentation are treated with multiple combinations of medications for pain control including ketorolac, liposomal bupivacaine, bupivacaine, and intravenous and oral narcotics. There is no current consensus on the optimal combination; therefore, all are used at the discretion of the surgeon. METHODS This was a single-center, retrospective study. The total number of patients included was 132. Comparisons were made between 4 groups: bupivacaine only (B); bupivacaine and liposomal bupivacaine (BL); bupivacaine and liposomal bupivacaine plus intraoperative ketorolac (BLKi); and bupivacaine and liposomal bupivacaine plus postoperative ketorolac (BLKp). Average pain scores immediately postoperative and before discharge were recorded and correlated to percentage of patients who received narcotic in the post-anesthesia care unit (PACU). Additional end points noted were side effects including nausea and time spent in PACU postoperatively. RESULTS Those receiving intraoperative ketorolac had the lowest pain on discharge (P < 0.0001) and the lowest percentage of patients receiving narcotics (P = 0.009) out of all 4 groups. There was no significant difference between the 4 groups in terms of time spent in PACU, pain immediately after the procedure, or amount of antiemetic given. No bleeding complications were noted for those who did or did not receive ketorolac. CONCLUSIONS When given options for pain control in breast augmentation, intraoperative ketorolac should be considered, because its inclusion was significant in decreasing use of narcotics and pain upon discharge. Addition of other costly drugs such as liposomal bupivacaine may not provide additional benefit in the immediate postoperative setting for procedures with a short recovery period such as breast augmentation.
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Affiliation(s)
- Pamela Tan
- Tulane University Division of Plastic and Reconstructive Surgery, New Orleans, LA
| | - Morgan Martin
- Tulane University Division of Plastic and Reconstructive Surgery, New Orleans, LA
| | - Nina Shank
- Tulane University Division of Plastic and Reconstructive Surgery, New Orleans, LA
| | - Leann Myers
- Tulane University Department of Biostatistics and Bioinformatics, New Orleans, LA
| | - Emily Wolfe
- Tulane University Division of Plastic and Reconstructive Surgery, New Orleans, LA
| | - John Lindsey
- Tulane University Division of Plastic and Reconstructive Surgery, New Orleans, LA
| | - Stephen Metzinger
- Tulane University Division of Plastic and Reconstructive Surgery, New Orleans, LA
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