Postoperative analgesic effect of locally infiltrated levobupivacaine in fleur-de-Lys abdominoplasty

Multimodal Pain Control in Abdominoplasty: A Systematic Review and Algorithm of Optimal Pain Management

The procedure with the highest rate of opioid prescription in plastic surgery is abdominoplasty. Additionally, plastic surgery patients are at a particularly elevated risk of becoming opioid-dependent. The main objective of this study was to perform a systematic review and create an algorithm for a multimodal pain regimen specific to patients undergoing abdominoplasty. A systematic search of the research literature was performed to summarize the prevailing understanding of multimodal pain control in the management of abdominoplasty. The initial search yielded 448 articles. Sixty-eight manuscripts were identified for full-text review. The effectiveness of current strategies was evaluated by way of pain scores, opioid usage, and length of stay, as well as other measures of physical function such as time to early mobilization. In 32 studies involving 2451 patients, the efficacy of different pain regimens during abdominoplasty was evaluated. Among nontraditional, opioid-sparing analgesia, efficacy of treatment interventions for improved pain and decreased opioid usage was found inall studies. Among local infusion studies, efficacy of treatment interventions for improved pain and decreased opioid usage was found in 78% of studies. Last, among regional block studies, efficacy of treatment interventions for improved pain was found in 87%, with 73% efficacy for decreased opioid usage. Multimodal pain regimens in abdominoplasty have the potential to play an important role in opioid-sparing practices in medicine by incorporating nonopioid pain adjuvants such as nonsteroidal anti-inflammatory drugs and transversus abdominis plane blocks in the preoperative, perioperative, and postoperative periods.

LEVEL OF EVIDENCE: 2

Efficacy of Incisional Ropivacaine Infiltration by Presternal Multi-Orifice Catheter for Post-sternotomy Pain Relief in Pediatric Patients Undergoing Cardiac Surgery: A Prospective, Randomized, Controlled Study

OBJECTIVE

To evaluate the efficacy of incisional ropivacaine infiltration by presternal multi-orifice catheter to manage poststernotomy pain in pediatric cardiac surgery.

DESIGN

A prospective, randomized, and double-blind comparative study.

SETTING

At a single-institution tertiary referral cardiac center.

PARTICIPANTS

The study comprised 200 children undergoing cardiac surgeries through a midline sternotomy.

INTERVENTIONS

Children were allocated randomly to 1 of 3 groups. Group A (n = 65) and group B (n = 64) received 0.375% ropivacaine infusion and intermittent bolus, respectively, by presternal multi-orifice catheter, whereas Group C (n = 64) did not receive any local anesthetic (LA) drug. Postoperatively, intravenous paracetamol was used for multimodal analgesia, and fentanyl was given as rescue analgesia, respectively.

MEASUREMENTS AND MAIN RESULTS

Pain was assessed by a Modified Objective Pain Score (MOPS) for 48 hours postextubation. Group B had significantly lower early MOPS at the first hour, but in the later period, the mean MOPS was lower in group A. The requirement of the first rescue analgesia was 3 ± 1.51, 6.1 ± 2.26, and 2.6 ± 0.87 hours for groups A (n = 60), B (n = 60), and C (n = 60), respectively. The 48-hour fentanyl consumption was significantly lower (p < 0.001) in group A (0.5 ± 0.68 µg/kg) and group B (0.7 ± 0.86 µg/kg) than the control group (3.4 ± 0.68 µg/kg). The length of intensive care unit stay was lower (p < 0.001) in groups A and B than in group C; however, the length of hospital stay was comparable (p = 0.07).

CONCLUSION

LA bolus and infusion through presternal multi-orifice catheter provided effective analgesia postoperatively. However, the bolus was more efficacious in the early phase but equivalent in later periods. Therefore, bolus and LA infusion can be used for steady poststernotomy pain relief in children undergoing cardiac surgeries.

Dexamethasone and dexmedetomidine as adjuvants to ropivacaine do not prolong analgesia in wound infiltration for lumbar spinal fusion: a prospective randomized controlled study

BACKGROUND AND OBJECTIVES

Local anesthetics (LAs) are widely used to infiltrate into surgical wounds for postoperative analgesia. Different adjuvants like dexamethasone and dexmedetomidine, when added to LA agents, could improve and prolong analgesia. The aim of this trial was to evaluate the analgesic efficacy and opioid-sparing properties of dexamethasone and dexmedetomidine when added to ropivacaine for wound infiltration in transforaminal lumbar interbody fusion (TLIF).

METHODS

We conducted a controlled study among 68 adult patients undergoing TLIF, which was prospective, randomized and double-blind in nature. The participants were divided into four equal groups at random. Group R was given 150 mg of 1% ropivacaine (15 mL) and 15 mL of normal saline. Group R + DXM received 150 mg of 1% ropivacaine (15 mL) and 10 mg of dexamethasone (15 mL). Group R + DEX received 150 mg of 1% ropivacaine (15 mL) and 1 µg/kg of dexmedetomidine (15 mL). Lastly, group R + DXM + DEX was given 150 mg of 1% ropivacaine (15 mL), 10 mg of dexamethasone and 1 µg/kg of dexmedetomidine (15 mL). The primary focus was on the length of pain relief provided. Additionally, secondary evaluations included the amount of hydromorphone taken after surgery, the numerical rating scale and safety assessments within 48 h after the operation.

RESULTS

Based on the p value (P > 0.05), there was no significant variance in the duration of pain relief or the total usage of hydromorphone after surgery across the four groups. Similarly, the numerical rating scale scores at rest and during activity at 6-, 12-, 24- and 48-h post-surgery for all four groups showed no difference (P > 0.05). However, the incidence of delayed anesthesia recovery was slightly higher in group R + DEX and group R + DXM + DEX when compared to group R or group R + DXM. Furthermore, there were no significant differences between the four groups in terms of vomiting, nausea, dizziness or delayed anesthesia recovery.

CONCLUSION

For wound infiltration in TLIF, the addition of dexamethasone and dexmedetomidine to ropivacaine did not result in any clinically significant reduction in pain or opioid consumption and could prompt some side effects.

Optimizing Nonopioid Analgesia and Different Pain Management Options following Abdominoplasty: A Systematic Literature Review

Introduction:

Postoperative pain remains a significant challenge with the growing number of abdominoplasties every year. Opioids are currently considered the mainstay modality for controlling postoperative pain. However, opioid-related side effects raise the need for a safer and more effective approach. In this study, we aimed to investigate these alternative evidence-based postoperative pain relief modalities following abdominoplasty.

Methods:

This systematic review was designed and conducted using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The literature was systematically searched in December 2021 using the following databases: MEDLINE, Cochrane, and EMBASE. The MeSH terms used to aid the search were the following: abdominoplasty, postoperative pain management, postoperative analgesia, pain control, analgesia, and pain.

Results:

Reviewing the literature resulted in a total of 851 publications. After implementing our criteria, only 13 articles were included in this study, with 990 patients. A continuous infusion pump was the most commonly used method of analgesia (n = 3), followed by a transversus abdominis plane block (n = 2). The postoperative pain assessment scale was mentioned in nine out of the 13. Compared to controls, all interventions resulted in considerably lower pain levels in all the patients. Patient satisfaction was reported in three studies, and all studies reported higher satisfaction rates than the control groups.

Conclusions:

The authors performed a systematic review of the existing database of high-quality research on pain management after cosmetic abdominoplasty to determine the best pain management options currently available. However, future studies are recommended to assess the optimum dosing and administration methods.

Painless, Drainless Lipoabdominoplasty: A Retrospective Study of Pain Following Lipoabdominoplasty Utilizing Liposomal Bupivacaine and a Modified Enhanced Recovery After Surgery Protocol

Background

There are many functional and aesthetic benefits to lipoabdominoplasty (combination of liposuction with abdominoplasty), including increase in core strength, reduction in urinary incontinence, and improvement in lower back pain. However, patients are still hesitant to undergo surgery due to the perceived fears of postsurgical drains, and postoperative pain.

Objectives

To propose a standardized multimodal pain protocol for patients undergoing lipoabdominoplasty procedures that aims to improve postoperative pain control.

Methods

A total of 80 patients operated on between July 2020 and December 2021 were evaluated in this study. Patients all underwent lipoabdominoplasty and were administered a standardized preoperative, intraoperative, and postoperative pain regimen. Pain scores were measured across all patients in the immediate postoperative period, and postoperative days (PODs) 1, 7, 28, and 90.

Results

Mean pain scores in the postanesthesia recovery unit were 0.46/10 (+/- 0.18). Subsequent reassessment in the postop recovery suite yielded mean pain scores of 0.34 (+/- 0.15). Mean pain scores on POD1 were 1.23 (+/- 0.15) and consistent through to POD7 at 1.24 (+/- 0.11) with patients taking an average of 6.65 total Percocet 5 mg (Endo Pharmaceuticals Inc., Malvern, PA) during the week. After POD7, 95% (76/80) of patients were only taking nonsteroidal anti-inflammatory drugs. A total of 75/80 patients (93.75%) reported zero pain at 4 to 6 weeks after surgery (mean pain score 0.10 +/- 0.08).

Conclusions

The multimodal analgesia protocol consisting of preoperative or immediate induction intravenous Tylenol (Johnson & Johnson, New Brunswick, NJ), precut local analgesia with Marcaine (Pfizer Inc., New York, NY) and lidocaine, and intraoperative use of liposomal bupivacaine can improve perioperative pain control in patients undergoing lipoabdominoplasty.

Level of Evidence 4

Transversus Abdominis Plane (TAP) Block: A Comparative Study between Levobupivacaine versus Levobupivacaine plus Ketamine in Abdominoplasty

Purpose

We conducted this study to explore the hypothesis that the addition of ketamine to levobupivacaine in ultrasound-guided Transversus Abdominis Plane (TAP) block would result in a better and prolonged duration of postoperative analgesia for patients undergoing abdominoplasty. Material and Methods. This randomized prospective study was conducted on 50 patients who were scheduled for abdominoplasty. TAP block was performed bilaterally for all patients either with levobupivacaine 0.5% 15 ml plus ketamine 0.5 mg/kg in a total volume of 20 ml in the LK group (n = 25) or with levobupivacaine 0.5% 15 ml plus 5 ml normal saline in a total volume of 20 ml in the L group on each side.

Results

Visual analogue scale (VAS) was significantly lower in the LK group in resting condition at 6, 12, and 16 h postoperatively compared to the L group. On movement, the VAS was significantly lower at 4, 6, 8, 12, 16, and 24 h postoperatively in the LK group compared to the L group. The time for first rescue analgesia was longer in the LK group (18.7 ± 4.8 h) than that in the L group (6.5 ± 2.4 h) with the reduced total amount of rescue morphine in the LK group (1.14 ± 2.2 mg) versus the L group (5.86 ± 3.6 mg). Only six patients in the LK group requested rescue morphine, whereas nineteen patients requested rescue morphine in the L group.

Conclusions

In TAP block, adding ketamine 0.5 mg/kg enhanced the analgesic efficacy of levobupivacaine 0.5% in patients undergoing abdominoplasty and reduced the required analgesics postoperatively.

Wound infiltration with ropivacaine as an adjuvant to patient controlled analgesia for transforaminal lumbar interbody fusion: a retrospective study

Background

Surgical procedure usually causes serious postoperative pain and poor postoperative pain management negatively affects quality of life, function and recovery time. We aimed to investigate the role of wound infiltration with ropivacaine as an adjuvant to patient controlled analgesia (PCA) in postoperative pain control for patients undergoing transforaminal lumbar interbody fusion.

Methods

One hundred twelve patients undergoing lumbar fusion were retrospectively reviewed and divided into two groups (ropivacaine and control groups) according to whether received wound infiltration with ropivacaine or not. Visual Analogue Scale (VAS) score, analgesics consumption, number of patients requiring rescue analgesic, hospital duration and incidence of complications were recorded. Surgical trauma was assessed using operation time, intraoperative blood loss and incision length.

Results

The amount of sufentanil consumption in ropivacaine group at 4 h postoperatively was lower than that of control group (24.5 ± 6.0 μg vs 32.1 ± 7.0 μg, P < 0.001) and similar results were observed at 8, 12, 24, 48 and 72 h postoperatively(P < 0.001). Fewer patients required rescue analgesia within 4 to 8 h postoperatively in ropivacaine group (10/60 vs 19/52, P = 0.017). Length of postoperative hospital durations were shorter in patients receiving ropivacaine infiltration compared to control cohorts (6.9 ± 0.9 days vs 7.4 ± 0.9 days, P = 0.015). The incidence of PONV in ropivacaine group was lower than that in control group (40.4% vs 18.3%, P = 0.01). However, VAS scores were similar in two groups at each follow-up points postoperatively, and no difference was observed(P > 0.05).

Conclusion

Wound infiltration with ropivacaine effectively reduces postoperative opioid consumption and PONV and may be a useful adjuvant to PCA to improve recovery for patients undergoing lumbar spine surgery.

Comparison of Different Surgical Procedures with Local Infiltration Analgesia in Day Surgery

Purpose of this study was assessing of local infiltration analgesia (LIA) with levobupivacaine on the trend of acute postoperative pain and outcome in individuals who underwent rhinoplasty procedure and abdominoplasty performed in general anaesthesia. The research was conducted on 60 patients, of which 30 patients underwent rhinoplasty procedure and the other 30 patients underwent abdominoplasty procedure in general anaesthesia with LIA in “Bagatin” Polyclinic in the time period between 01.01.2014. and 01.01.2017. Postoperative analgesics doses on the same day of surgery were noted in 85% of participants who underwent an abdominoplasty procedure and in 45% of participants underwent rhinoplasty procedure. Patients who underwent abdominoplasty were discharged from the facility within 48 hours, while all patients who underwent rhinoplasty procedure were discharged on the same day of the surgery. During the first postoperative day patients who underwent a rhinoplasty procedure did not require analgesics, while only 3% of patients who underwent an abdominal liposuction procedure required an additional dose of analgesics. The research results had shown, when LIA was performed, the manifestation of acute postoperative pain and vomiting did not lead to prolonged stay in day surgery.

INFLUENCE OF LOCAL INFILTRATION ANALGESIA ON POSTOPERATIVE PAIN IN ABDOMINOPLASTY PATIENTS

The aim of this study was the influence of local infiltrating analgesia with levobupivacaine on acute postoperative pain in patients that underwent abdominoplasty in day surgery. Local infiltration anesthesia is an injection of local anesthetic solution in painful areas. General anesthesia and tumescent fluid solution were performed in all patients. The study included 55 patients within age range from 20 to 72 years old. Study was conducted from January 2016 to February 2019.Postoperative pain after abdominoplasty was evaluated. LIA were performed before closure of abdominal wall after resection of skin and subcutaneous fat in lower part of abdominal wall. Infiltration was performed after plication of rectus abdominis muscles with single shot of 40 ml 0.25% Bupivacaine. Postoperative pain was reduced in the abdominal wall and in the wound area around umbilicus and in lower abdomen scar after waking from general anesthesia. Occurrence of acute postoperative was noticed in all participants. 85% of patients required an additional dose of analgesics and only in 3% of patients was required during the first postoperative day discharged during 48 hours. The research has shown that the appearance of acute postoperative pain did not lead to prolonged stay in the facility for day surgery.

Surgically-assisted abdominal wall blocks for analgesia after abdominoplasty: A prospective randomized trial

BACKGROUND

Abdominoplasty is a common aesthetic procedure. The transversus abdominis plane block (TAPB) and rectus sheath block (RSB) have proven efficacy as analgesic modality for abdominal surgeries. This study demonstrates post-abdominoplasty analgesic duration consequent to the three surgically infiltrated local anesthetic techniques: bilateral TAPB, bilateral RSB, and subcutaneous infiltration (SCI) of 0.25% bupivacaine.

METHODS

In this prospective randomized study, 48 adult patients scheduled for abdominoplasty were randomized into three groups: TAPB group (n = 16), RSB group (n = 16), and SCI group (n = 16) utilizing 40 mL of 0.25% bupivacaine for each block. In both TAPB and RSB groups, the block was performed bilaterally after plication of anterior abdominal wall, while in SCI group, the surgical incisional area was infiltrated before skin closure. Main outcome measures included visual analogue scale (VAS), at rest and during movement; the analgesic duration; and the total required doses of morphine in the first postoperative day.

RESULTS

A statistically significant longer analgesia was recorded in the TABP group compared with both the RSB and SCI groups. Statistically significant higher VAS scores in the SCI group 4 hours postoperatively was recorded, both at rest and during movement, compared with both TABP and RSB groups. Significant higher morphine consumption in the SCI group was compared with the other two groups.

CONCLUSIONS

Among the surgically infiltrated anesthetic techniques for abdominoplasty, bilateral TAPB was associated with longer postoperatively analgesic duration with lower morphine consumption in the first 24 hours compared with RSB and SCI.

Comparison of preincisional infiltrated levobupivacaine and ropivacaine for acute postoperative pain relief after septorhinoplasty

BACKGROUND

To maintain a high standard of patient care, it is essential to provide adequate pain management in patients who undergo nasal surgery. Levobupivacaine and ropivacaine are relatively new long-acting local anesthetics.

OBJECTIVE

The aim of this study was to compare the analgesic effect and blood loss of preincisional levobupivacaine HCl 0.25% and ropivacaine HCl 0.375% in patients undergoing septorhinoplasty.

METHODS

Sixty American Society of Anesthesiologists (ASA) I and II patients (18-55 years old) who were scheduled for elective open technique septorhinoplasty under general anesthesia were recruited for this study. The anesthetic technique was standardized for both groups. Preoperative and postoperative hemoglobin levels were recorded for all patients. Patients were assigned randomly to 1 of 2 study groups, and preincisional surgical field infiltration with 5 mL of 0.5% levobupivacaine plus 5 mL of 0.9% saline (group L; n = 30) or 5 mL of 0.75% ropivacaine plus 5 mL of 0.9% saline (group R; n = 30) was performed by the same surgeon. The degree of pain was measured by visual analogue scale (VAS) for pain and recorded at multiple time points in all patients after surgery.

RESULTS

The analgesic effect at 2 hours in the postanesthesia care unit (PACU) and at 24 hours postoperatively did not differ significantly between the 2 local anesthetics (P > 0.05). Pain scores of patients decreased after the 24 hours in levobupivacaine group and ropivacaine group when compared with 0-minute VAS values, and this was statistically significant (P < 0.05). No significant difference was observed between groups with respect to the preoperative and postoperative hemoglobin (P = 0.767 and 0.824, respectively) values.

CONCLUSIONS

Local tissue infiltration with 0.25% levobupivacaine or 0.375% ropivacaine is similarly effective in reducing the postoperative pain associated with septorhinoplasty.

Local anesthesia for treatment of hernia in elder patients: Levobupicavaine or Bupivacaine?

Background

Inguinal hernia is one of the most common diseases in the elderly. Treatment of this pathology is exclusively surgical and relies almost always on the use of local anesthesia. While in the past hernia surgery was carried out mainly by general anesthesia, in recent years there has been growing emphasis on the role of local anesthesia.

Methods

The aim of our study was to compare intra-and postoperative analgesia obtained by the use of levobupivacaine to the same obtained by bupivacaine. Bupivacaine is one of the main local anesthetics used in the intervention of inguinal hernioplasty. Levobupivacaine is an enantiomer of racemic bupivacaine with less cardiotoxicity and neurotoxicity. The study was conducted from March 2011 to March 2013. We collected data of eighty patients, male and female, aged between 65 and 86 years, who underwent inguinal hernioplasty with local anesthesia.

Results

Evaluation of intra-operatively pain shows that minimal pain is the same in both groups. Mild pain was more frequent in the group who used levobupivacaine. Moderate pain was slightly more frequent in the group who used bupivacaine. Only one reported intense pain. Two drugs seem to have the same effect at a distance of six, twelve, eighteen and twentyfour hours. Bupivacaine shows a significantly higher number of complications, as already demonstrated by previous studies. Degree of satisfaction expressed by patients has been the same in the two groups. Levobupivacaine group has shown a greater request for paracetamol while patients who experienced bupivacaine have showed a higher request of other analgesics.

Conclusions

Clinical efficacy of levobupivacaine and racemic bupivacaine are actually similar, when used under local intervention of inguinal hernioplasty. In the field of ambulatorial surgery our working group prefers levobupivacaine for its fewer side effects and for its easy handling.

Comparative study between Levobupivacaine and Bupivacaine for hernia surgery in the elderly

Background

The inguinal hernia is one of the most common diseases in the elderly. Treatment of this type of pathology is exclusively surgical and relies almost always on the use of local anesthesia. While in the past hernia surgery was carried out mainly by general anesthesia, in recent years there has been growing emphasis on the role of local anesthesia.

Methods

The aim of our study was to compare intra-and postoperative analgesia obtained by the use of levobupivacaine compared with that of bupivacaine. Bupivacaine is one of the main local anesthetics used in the intervention of inguinal hernioplasty. Levobupivacaine is an enantiomer of racemic bupivacaine with less cardiotoxicity and neurotoxicity. The study was conducted from April 2010 to May 2012. We collected data of forty male patients, aged between 73 and 85 years, who underwent inguinal hernioplasty with local anesthesia for the first time.

Results

Minimal pain is the same in both groups. Mild pain was more frequent in the group who used bupivacaine, moderate pain was slightly more frequent in the group who used levobupivacaine, and the same for intense pain. It is therefore evident how Bupivacaine is slightly less preferred after four and twenty four hours, while the two drugs seem to have the same effect at a distance of twelve and forty-eight hours. Bupivacaine shows a significantly higher number of complications, as already demonstrated by previous studies. The request for an analgesic was slightly higher in patients receiving levobupivacaine.

Conclusions

After considering all these elements, we can conclude that the clinical efficacy of levobupivacaine and racemic bupivacaine are essentially similar, when used under local intervention of inguinal hernioplasty.

Postoperative continuous paravertebral anesthetic infusion for pain control in lumbar spinal fusion surgery

STUDY DESIGN

A retrospective, case-control study was conducted to analyze postoperative outcomes in patients who received local anesthetic infusion pumps after lumbar spinal fusion procedures. Data were collected prospectively via nursing protocol and third party assessment, and analyzed retrospectively.

OBJECTIVE

To review the safety and efficacy of continuous infusion of local anesthetic into the subfascial aspects of the wound after lumbar fusion surgery for treatment of postoperative pain, and to determine whether other outcome measures such as postoperative nausea and vomiting, ambulation and length of hospitalization were affected by the presence of the device.

SUMMARY OF BACKGROUND DATA

Patients who undergo lumbar spine fusion procedures frequently experience significant, debilitating pain related to their surgery. This pain may delay postoperative mobilization, increase length of hospitalization, and require prolonged use of high doses of narcotics. Use of a local anesthetic continuous-infusion pump after surgery may lead to improvements in these outcome variables.

METHODS

After posterior lumbar spine fusion procedures, 26 consecutive patients received the ON-Q PainBuster, which infused 0.5% marcaine via an elastomeric pump into the subfascial aspects of the wound. Retrospective analysis compared each of these patients with a case-matched control patient. Data included pain scores and opiate use during the first 5 postoperative days (PODs), length of hospital stay, and complications. Variables such as age, American Society of Anesthesiologists (ASA) physical status, and surgical procedure were similar between matched cases. One patient was excluded because of active heroine abuse.

RESULTS

Patients with the ON-Q PainBuster used 41.2% less narcotics on POD 1, 50.1% less on day 2, and 47.1% less on day 3 compared with the control patients. Differences in opiate usage were not statistically significant on POD 4 (45.5% less) and 5 (50.3% less). A lower average pain score was observed among patients with the ON-Q PainBuster on each POD: 39.1% less pain on POD 1, 34.0% on day 2, 45.1% on day 3, 29.5% on day 4, and 43.6% on day 5. No differences were observed in length of hospital stay or complication rate.

CONCLUSION

Patients who received the ON-Q PainBuster used less narcotic medications than case-matched patients during the first 3 PODs, and reported lower pain scores during the first 5 PODs. No complications attributable to the device were noted. These results suggest that continuous infusion of local anesthetic into the wound during the immediate postoperative period is a safe and effective technique that results in lower pain scores and narcotic use. Further data may reveal additional benefits such as lower incidence of nausea and vomiting and decreased times to mobility and functional independence.