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Zhao M, Zhou M, Lu P, Wang Y, Zeng R, Liu L, Zhu S, Kong L, Zhang J. Local anesthetic delivery systems for the management of postoperative pain. Acta Biomater 2024; 181:1-18. [PMID: 38679404 DOI: 10.1016/j.actbio.2024.04.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 03/29/2024] [Accepted: 04/23/2024] [Indexed: 05/01/2024]
Abstract
Postoperative pain (POP) is a major clinical challenge. Local anesthetics (LAs), including amide-type LAs, ester-type LAs, and other potential ion-channel blockers, are emerging as drugs for POP management because of their effectiveness and affordability. However, LAs typically exhibit short durations of action and prolonging the duration by increasing their dosage or concentration may increase the risk of motor block or systemic local anesthetic toxicity. In addition, techniques using LAs, such as intrathecal infusion, require professional operation and are prone to catheter displacement, dislodgement, infection, and nerve damage. With the development of materials science and nanotechnology, various LAs delivery systems have been developed to compensate for these disadvantages. Numerous delivery systems have been designed to continuously release a safe dose in a single administration to ensure minimal systemic toxicity and prolong pain relief. LAs delivery systems can also be designed to control the duration and intensity of analgesia according to changes in the external trigger conditions, achieve on-demand analgesia, and significantly improve pain relief and patient satisfaction. In this review, we summarize POP pathways, animal models and methods for POP testing, and highlight LAs delivery systems for POP management. STATEMENT OF SIGNIFICANCE: Postoperative pain (POP) is a major clinical challenge. Local anesthetics (LAs) are emerging as drugs for POP management because of their effectiveness and affordability. However, they exhibit short durations and toxicity. Various LAs delivery systems have been developed to compensate for these disadvantages. They have been designed to continuously release a safe dose in a single administration to ensure minimal toxicity and prolong pain relief. LAs delivery systems can also be designed to control the duration and intensity of analgesia to achieve on-demand analgesia, and significantly improve pain relief and patient satisfaction. In this paper, we summarize POP pathways, animal models, and methods for POP testing and highlight LAs delivery systems for POP management.
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Affiliation(s)
- Mingxu Zhao
- Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical University, Key Laboratory of Anesthesia and Perioperative Medicine of Anhui Higher Education Institutes, Anhui Medical University, Hefei, 230032, China; Department of Anesthesiology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui 230031, China
| | - Mengni Zhou
- Reproductive Medicine Center, Department of Obstetrics and Gynecology, The First Affiliated Hospital of Anhui Medical University, Hefei, 230032, China
| | - Pengcheng Lu
- Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical University, Key Laboratory of Anesthesia and Perioperative Medicine of Anhui Higher Education Institutes, Anhui Medical University, Hefei, 230032, China
| | - Ying Wang
- Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical University, Key Laboratory of Anesthesia and Perioperative Medicine of Anhui Higher Education Institutes, Anhui Medical University, Hefei, 230032, China
| | - Rong Zeng
- Department of Anesthesiology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui 230031, China
| | - Lifang Liu
- Department of Anesthesiology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui 230031, China
| | - Shasha Zhu
- Reproductive Medicine Center, Department of Obstetrics and Gynecology, The First Affiliated Hospital of Anhui Medical University, Hefei, 230032, China.
| | - Lingsuo Kong
- Department of Anesthesiology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui 230031, China.
| | - Jiqian Zhang
- Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical University, Key Laboratory of Anesthesia and Perioperative Medicine of Anhui Higher Education Institutes, Anhui Medical University, Hefei, 230032, China.
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King GA, Le A, Nickol M, Sarkis B, van der Merwe JM. Periarticular infiltration used in total joint replacements: an update and review article. J Orthop Surg Res 2023; 18:859. [PMID: 37957753 PMCID: PMC10641975 DOI: 10.1186/s13018-023-04333-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 10/31/2023] [Indexed: 11/15/2023] Open
Abstract
Periarticular infiltration following total knee and hip arthroplasty has been demonstrated to be equivalent to peripheral nerve blocks for postoperative pain management. The ideal cocktail has not been established yet. We have conducted a literature search on PubMed and Embase. Our search criteria included randomized controlled trials (RCTs) and systematic reviews (SRs). We tried to only include the most recent studies to keep the information current. The included research focused at Dexmedetomidine, Liposomal Bupivacaine, Ropivacaine, Epinephrine, Ketorolac, Morphine, Ketamine and Glucocorticosteroids. Each medication's mode of action, duration, ideal dosage, contraindications, side effects and effectiveness have been summarized in the review article. This article will help the clinician to make an informed evidence-based decision about which medications to include in their ideal cocktail.
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Affiliation(s)
- Gavin Anthony King
- College of Medicine - Department of Orthopaedic Surgery, University of Saskatchewan, Saskatoon, Canada
| | - Alexander Le
- College of Medicine - Department of Orthopaedic Surgery, University of Saskatchewan, Saskatoon, Canada
| | - Michaela Nickol
- College of Medicine - Department of Orthopaedic Surgery, University of Saskatchewan, Saskatoon, Canada
| | - Bianca Sarkis
- College of Medicine - Department of Orthopaedic Surgery, University of Saskatchewan, Saskatoon, Canada
- Faculty of Medicine - Division of Orthopaedic Surgery, University of Montreal, Montreal, Canada
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Peripheral Regional Anesthesia Using Local Anesthetics: Old Wine in New Bottles? J Clin Med 2023; 12:jcm12041541. [PMID: 36836081 PMCID: PMC9962037 DOI: 10.3390/jcm12041541] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 02/08/2023] [Accepted: 02/13/2023] [Indexed: 02/18/2023] Open
Abstract
During the past decade, numerous efforts were undertaken aiming at prolonging the analgesic effect of regional anesthesia. With the development of extended-release formulations and enhanced selectivity for nociceptive sensory neurons, a very promising contribution to the development of pain medications has been achieved. At present, liposomal bupivacaine is the most popular, non-opioid, controlled drug delivery system, but its duration of action, which is still controversially discussed, and its expensiveness have decreased initial enthusiasm. Continuous techniques can be seen as an elegant alternative for providing a prolonged duration of analgesia, but for logistic or anatomical reasons, they are not always the best choice. Therefore, focus has been directed towards the perineural and/or intravenous addition of old and established substances. As for perineural application, most of these so-called 'adjuvants' are used outside their indication, and their pharmacological efficacy is often not or only poorly understood. This review aims to summarize the recent developments for prolonging the duration of regional anesthesia. It will also discuss the potential harmful interactions and side effects of frequently used analgesic mixtures.
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Jiang H, Ma Q, Dong J, Ye X. The effect of liposomal bupivacaine for surgical wound infiltration: A meta‐analysis of randomised controlled trials. Int Wound J 2022; 20:1591-1608. [PMID: 36345868 PMCID: PMC10088822 DOI: 10.1111/iwj.14015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 10/24/2022] [Accepted: 10/26/2022] [Indexed: 11/11/2022] Open
Abstract
Liposomal bupivacaine (LB) has consistently been considered a potential analgesic for surgical wound infiltration. However, the evidence of its analgesic effectiveness remains unclear. In this meta-analysis, we attempted to identify the potential clinical role of LB wound infiltration in different surgical procedures. Randomised controlled trials (RCTs) comparing LB with non-liposomal local anaesthetics and placebos were retrieved from six electronic databases. The primary outcome was cumulative morphine equivalent consumption within 24, 48, and 72 hours after surgery. Approximately 2659 patients from 22 studies were included in the meta-analysis. Compared to the control, LB-wound infiltration did not reduce the postoperative morphine consumption at 24 hours (weighted mean difference [WMD], -0.60 mg; 97.5% confidence interval [CI], -2.78 to 1.59 mg; P = 0.54), 48 hours (WMD, -1.00 mg; 97.5% CI, -3.23 to 1.24; P = 0.32) or 72 hours (WMD, 0.50 mg; 97.5% CI, -0.67 to 1.67; P = 0.33). Similarly, secondary outcome analysis did not reveal any additional benefits of LB in any other pain-related outcomes. LB was not associated with any adverse effects. Overall, LB does not appear to improve the postoperative analgesic, rehabilitation, or safety outcomes. Current evidence does not support the routine use of LB for wound infiltration following surgical procedures.
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Affiliation(s)
- Hua Jiang
- Hospital of Chengdu University of Traditional Chinese Medicine Chengdu China
| | - Qiong Ma
- Hospital of Chengdu University of Traditional Chinese Medicine Chengdu China
| | - Jing Dong
- Hospital of Chengdu University of Traditional Chinese Medicine Chengdu China
| | - Xin Ye
- Hospital of Chengdu University of Traditional Chinese Medicine Chengdu China
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Drapeau-Zgoralski V, Bourget-Murray J, Hall B, Horton I, Dervin G, Duncan K, Addy K, Garceau S. Surgeon-Performed Intraoperative Peripheral Nerve Blocks and Periarticular Infiltration During Total Hip and Knee Arthroplasty: A Critical Analysis Review. JBJS Rev 2022; 10:01874474-202211000-00006. [PMID: 36574407 DOI: 10.2106/jbjs.rvw.22.00105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
➢ Surgeon-performed intraoperative peripheral nerve blocks may improve operating room efficiency and reduce hospital resource utilization and, ultimately, costs. Additionally, these blocks can be safely performed intraoperatively by most orthopaedic surgeons, while only specifically trained physicians are able to perform ultrasound-guided peripheral nerve blocks. ➢ IPACK (infiltration between the popliteal artery and capsule of the knee) blocks are at least noninferior to periarticular infiltration when combined with an adductor canal block for analgesia following total knee arthroplasty. ➢ Surgeon-performed intraoperative adductor canal blocks are technically feasible and offer reliable anesthesia comparable with ultrasound-guided blocks performed by anesthesiologists. While clinical studies have shown promising results, additional Level-I studies are required. ➢ A surgeon-performed intraoperative psoas compartment block has been described as a readily available and safe technique, although there is some concern for femoral nerve analgesia, and temporary sensory changes have been reported.
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Affiliation(s)
| | | | - Brandon Hall
- Faculty of Medicine, McGill University, Montreal, Quebec, Canada
| | - Isabel Horton
- Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Geoffrey Dervin
- Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Kenneth Duncan
- Division of Anesthesiology, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Keith Addy
- Division of Anesthesiology, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Simon Garceau
- Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
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Hannon CP, Fillingham YA, Spangehl MJ, Karas V, Kamath AF, Casambre FD, Verity TJ, Nelson N, Hamilton WG, Della Valle CJ. The Efficacy and Safety of Periarticular Injection in Total Joint Arthroplasty: A Direct Meta-Analysis. J Arthroplasty 2022; 37:1928-1938.e9. [PMID: 36162925 DOI: 10.1016/j.arth.2022.03.045] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 02/23/2022] [Accepted: 03/12/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Periarticular injection (PAI) is administered intraoperatively to help reduce postoperative pain and opioid consumption after primary total joint arthroplasty (TJA). The purpose of this study was to evaluate the efficacy and safety of PAI in primary TJA to support the combined clinical practice guidelines of the American Association of Hip and Knee Surgeons, American Academy of Orthopaedic Surgeons, Hip Society, Knee Society, and American Society of Regional Anesthesia and Pain Medicine. METHODS The MEDLINE, Embase, and Cochrane Central Register of Controlled Trials databases were searched for studies published prior to March 2020 on PAI in TJA. All included studies underwent qualitative and quantitative homogeneity testing followed by a systematic review and direct comparison meta-analysis to assess the efficacy and safety of PAI. RESULTS Three thousand six hundred and ninety nine publications were critically appraised to provide 60 studies regarded as the best available evidence for an analysis. The meta-analysis showed that intraoperative PAI reduces postoperative pain and opioid consumption. Adding ketorolac or a corticosteroid to a long-acting local anesthetic (eg, ropivacaine or bupivacaine) provides an additional benefit. There is no difference between liposomal bupivacaine and other nonliposomal long-acting local anesthetics. Morphine does not provide any additive benefit in postoperative pain and opioid consumption and may increase postoperative nausea and vomiting. There is insufficient evidence to draw conclusions on the use of epinephrine and clonidine. CONCLUSION Strong evidence supports the use of a PAI with a long-acting local anesthetic to reduce postoperative pain and opioid consumption. Adding a corticosteroid and/or ketorolac to a long-acting local anesthetic further reduces postoperative pain and may reduce opioid consumption. Morphine has no additive effect and there is insufficient evidence on epinephrine and clonidine.
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Affiliation(s)
- Charles P Hannon
- Department of Orthopedic Surgery, Washington University in St. Louis, St. Louis, MO
| | | | | | - Vasili Karas
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL
| | - Atul F Kamath
- Department of Orthopedic Surgery, Cleveland Clinic Foundation, Cleveland, OH
| | - Francisco D Casambre
- Department of Clinical Quality and Value, American Academy of Orthopaedic Surgeons, Rosemont, IL
| | - Tyler J Verity
- Department of Clinical Quality and Value, American Academy of Orthopaedic Surgeons, Rosemont, IL
| | - Nicole Nelson
- Department of Clinical Quality and Value, American Academy of Orthopaedic Surgeons, Rosemont, IL
| | | | - Craig J Della Valle
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL
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Thuppal S, Sleiman A, Chawla K, Dynda D, Evans Q, Markwell S, Hazelrigg S, Crabtree T. Randomized Trial of Bupivacaine Versus Liposomal Bupivacaine in Minimally Invasive Lobectomy. Ann Thorac Surg 2022; 114:1128-1134. [PMID: 35331700 DOI: 10.1016/j.athoracsur.2022.02.058] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 01/24/2022] [Accepted: 02/22/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND The objective of this single-blind randomized study is to compare local infiltration of bupivacaine or liposomal bupivacaine (LipoB) in narcotic naïve patients undergoing minimally invasive lobectomy for early stage lung cancer. METHODS Adult patients without previous lung surgery undergoing minimally invasive lobectomy (robotic or thoracoscopic) for early stage lung cancer were randomly assigned to bupivacaine (with epinephrine 0.25%, 1:200 000) or LipoB 1.3%. Pain level was documented using the visual analog scale and morphine equivalents for narcotic pain medications. Inhospital treatment cost and pharmacy cost were compared. RESULTS The study enrolled 50 patients (bupivacaine, 24; LipoB, 26). The mean age of patients was 66 years, 94% were non-Hispanic white, and 48% were male. There was no difference in baseline characteristics and comorbidities. Duration of surgery (105 vs 137 minutes, P = .152), chest tube duration (49 vs 55 hours, P = .126), and length of stay (2.45 vs 3.28 days, P = .326) were similar between treatments. Inhospital morphine equivalents were 42.7 mg vs 48 mg (P = .714), and the median pain score was 5.2 vs 4.75 (P = .602) for bupivacaine vs LipoB, respectively. There was no difference in narcotic use at 2 to 4 weeks (57.1% [12 of 21] vs 54.5% [12 of 22], P = 1.00), and at 6 months (5.9% [1 of 17] vs 9.5% [2 of 21], P = 1.00) after surgery. The overall cost ($20 252 vs $22 775, P = .225) was similar; however, pharmacy cost for LipoB was higher ($1052 vs $596, P = .0001). CONCLUSIONS In narcotic naïve patients undergoing minimally invasive lobectomy, short-term narcotic use, postoperative pain scores, length of stay, and long-term narcotic use were similar between bupivacaine and LipoB.
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Affiliation(s)
- Sowmyanarayanan Thuppal
- Division of Cardiothoracic Surgery, Department of Surgery, Southern Illinois School of Medicine, Springfield, Illinois; Center for Clinical Research, Southern Illinois School of Medicine, Springfield, Illinois
| | - Anthony Sleiman
- Division of Cardiothoracic Surgery, Department of Surgery, Southern Illinois School of Medicine, Springfield, Illinois
| | - Kanika Chawla
- Division of Cardiothoracic Surgery, Department of Surgery, Southern Illinois School of Medicine, Springfield, Illinois
| | - Danuta Dynda
- Division of Cardiothoracic Surgery, Department of Surgery, Southern Illinois School of Medicine, Springfield, Illinois; Center for Clinical Research, Southern Illinois School of Medicine, Springfield, Illinois
| | - Quadis Evans
- Division of Cardiothoracic Surgery, Department of Surgery, Southern Illinois School of Medicine, Springfield, Illinois; Center for Clinical Research, Southern Illinois School of Medicine, Springfield, Illinois
| | - Stephen Markwell
- Division of Cardiothoracic Surgery, Department of Surgery, Southern Illinois School of Medicine, Springfield, Illinois
| | - Stephen Hazelrigg
- Division of Cardiothoracic Surgery, Department of Surgery, Southern Illinois School of Medicine, Springfield, Illinois
| | - Traves Crabtree
- Division of Cardiothoracic Surgery, Department of Surgery, Southern Illinois School of Medicine, Springfield, Illinois.
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Periarticular Injection in Total Joint Arthroplasty: The Clinical Practice Guidelines of the American Association of Hip and Knee Surgeons, American Society of Regional Anesthesia and Pain Medicine, American Academy of Orthopaedic Surgeons, Hip Society, and Knee Society. J Arthroplasty 2022; 37:1701-1707. [PMID: 35970572 DOI: 10.1016/j.arth.2022.03.048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 03/08/2022] [Accepted: 03/12/2022] [Indexed: 02/06/2023] Open
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Vij N, Supra R, Vanvalkenburg D, Comardelle N, Kaye AD, Viswanath O, Urits I. The role for high volume local infiltration analgesia with liposomal bupivacaine in total hip arthroplasty: A scoping review. Orthop Rev (Pavia) 2022; 14:37101. [DOI: 10.52965/001c.37101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 05/21/2022] [Indexed: 11/06/2022] Open
Abstract
Introduction Liposomal bupivacaine has been integrated into clinical practice within many surgical disciplines to reduce post-operative pain and opioid consumption. This novel agent has been utilized in this regard in many subdisciplines of orthopedic surgery. Total hip arthroplasty has significant opioid use post-operatively as compared to many other orthopedic disciplines. Objectives The purpose of the present investigation is to summarize the current use of liposomal bupivacaine after total hip arthroplasty and to shed light on the prospect of liposomal bupivacaine to reduce opioid use after total hip arthroplasty. A tertiary purpose is to identify future areas of adjunctive pain measures that can assist in the reduction of opioid use after total hip arthroplasty. Methods This IRB-exempt scoping review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist strictly. The literature search was performed in Mendeley. Search fields were varied until redundant. All articles were screened by title and abstract and a preliminary decision to include an article was made. The full-text screening was performed on the selected articles. Any question regarding the inclusion of an article was discussed by three authors until an agreement was reached. Results A total of 21 articles were included for qualitative description of the opioid epidemic, opioid overuse in total hip arthroplasty, and risk factors for opioid overuse in total hip arthroplasty. A total of 9 articles were included regarding the use of liposomal bupivacaine in total hip arthroplasty. Several risk factors have been identified for opioid overuse after total hip arthroplasty. These include younger age, an opioid risk tool score of > 7, a higher body mass index, chronic obstructive pulmonary disease, immunodeficiency syndromes, preexisting pain syndromes, peripheral vascular disease, anxiety and mood disorders, and substance abuse disorders. Liposomal bupivacaine reduces postoperative opioid use, patient-reported outcomes, length of stay, and time to ambulation, yet is more expensive than traditional bupivacaine. Conclusions Liposomal bupivacaine represents a useful adjunct for multimodal pain strategies in total hip arthroplasty with sufficient evidence to suggest that it may be useful in decreasing postoperative opioid use. The high costs of LB represent a barrier to institutional acceptance of LB into standardized multimodal pain strategies. Further efforts should be aimed toward better understanding the current state of integration of LB into academic and private practice settings, industry movements to decrease the cost, and the role other adjunctive measures may have in reducing post-operative opioid use.
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Affiliation(s)
- Neeraj Vij
- University of Arizona College of Medicine - Phoenix
| | | | | | | | - Alan D. Kaye
- Louisiana State University Health Sciences Center
| | | | - Ivan Urits
- Louisiana State University Health Shreveport
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Qiao Q, Fu X, Huang R, Lei S, Leng Y, Liu Z, Xia Z, Jiang X. Ropivacaine-loaded, hydroxypropyl chitin thermo-sensitive hydrogel combined with hyaluronan: an injectable, sustained-release system for providing long-lasting local anesthesia in rats. Reg Anesth Pain Med 2022; 47:234-241. [PMID: 35168948 DOI: 10.1136/rapm-2021-102726] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 12/31/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND OBJECTIVE Ropivacaine hydrochloride is a commonly used local anesthetic in clinics. However, local injection or continuous infusion of ropivacaine has been associated with several disadvantages. Accordingly, it is important to develop a new controlled release system for local administration of ropivacaine to achieve a prolong anesthetic effect, improve efficacy, and minimize the side effects. METHODS We developed injectable hydroxypropyl chitin thermo-sensitive hydrogel (HPCH) combined with hyaluronan (HA), which was used to synthesize a ropivacaine (R)-loaded controlled release system. We then conducted drug release test and cytotoxicity assay in vitro. Importantly, we examined the analgesic effects and biocompatibility of this system in vivo by injecting different concentrations of R-HPCH-HA (7.5, 15, 22.5 mg/mL), ropivacaine hydrochloride (RHCL, 7.5 mg/mL), or saline (all in 0.5 mL) near the sciatic nerve in rats. RESULTS R-HPCH-HA induced concentration-dependent thermal-sensory blockade and motor blockade in vivo. In hot plate test, R-HPCH-HA (22.5 mg/mL) induced a significant longer thermal-sensory blockade (17.7±0.7 hours), as compared with RHCL (7.5 mg/mL, 5.7±0.8 hours, n=6/group, p<0.05). It also produced a more prolonged motor blockade (6.8±0.8 hours) than RHCL (3.5±0.8 hours, p<0.05). R-HPCH-HA caused less cytotoxicity than RHCL, as indicated by the higher cell viability in vitro (n=8/group). CONCLUSION Our findings in a sciatic nerve block model demonstrated that the injectable, ropivacaine-loaded controlled release system effectively prolonged the local analgesic effect in rats without notable side effects.
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Affiliation(s)
- Qianqian Qiao
- Department of Anesthesiology, Renmin Hospital of Wuhan University, Wuhan, Hubei, China
| | - Xiangyun Fu
- Department of Anesthesiology, Renmin Hospital of Wuhan University, Wuhan, Hubei, China
| | - Rui Huang
- Department of Anesthesiology, Renmin Hospital of Wuhan University, Wuhan, Hubei, China
| | - Shaoqing Lei
- Department of Anesthesiology, Renmin Hospital of Wuhan University, Wuhan, Hubei, China
| | - Yan Leng
- Department of Anesthesiology, Renmin Hospital of Wuhan University, Wuhan, Hubei, China
| | - Zhigang Liu
- Department of Anesthesiology, Renmin Hospital of Wuhan University, Wuhan, Hubei, China
| | - Zhongyuan Xia
- Department of Anesthesiology, Renmin Hospital of Wuhan University, Wuhan, Hubei, China
| | - Xulin Jiang
- Key Laboratory of Biomedical Polymers of Ministry of Education and Department of Chemistry, Wuhan University, Wuhan, Hubei, China
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Dilawri A, Wyman M, Shah S. Liposomal Bupivacaine Versus Immediate-Release Bupivacaine for Postoperative Pain Control. Ann Pharmacother 2021; 56:664-670. [PMID: 34496675 DOI: 10.1177/10600280211043554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Liposomal bupivacaine (LB) is increasingly being used for postoperative pain control, but there are conflicting efficacy data when compared with immediate-release bupivacaine (IRB). OBJECTIVE To evaluate the comparative efficacies of LB and IRB for postoperative pain control in order to assess the formulary status of LB at our institution. METHODS A single-center, retrospective, institutional review board-approved, noninferiority matched cohort study at a tertiary care academic medical center. Adult surgical patients admitted for >24 hours who received LB or IRB were included. The primary outcome was total opioid consumption within 24 hours postoperatively. Secondary outcomes included total opioid consumption within 72 hours postoperatively, nonopioid analgesic use within 24 and 72 hours postoperatively, time to rescue analgesic use, and postoperative length of stay (LOS). RESULTS A total of 326 patients were included in the matched cohort. Median 24-hour opioid consumption was significantly lower in the IRB group compared with the LB group (81 mg [30, 153] vs 103 mg [46, 241]; P = 0.01). Patients receiving IRB compared with LB also had a decrease in total opioid consumption 72 hours postoperatively (110 mg [45, 258] vs 165 mg [68, 402]; P = 0.005) and shorter postoperative LOS (2.8 days [1.7, 4] vs 3.3 days [2, 5.1]; P < 0.001). There was no difference in time to rescue analgesic use. CONCLUSION AND RELEVANCE Across a variety of surgical procedures, administration of IRB compared with LB was associated with a reduction in total opioid consumption within 24 and 72 hours postoperatively and shorter LOS in adult surgical patients.
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Karam JA, Schwenk ES, Parvizi J. An Update on Multimodal Pain Management After Total Joint Arthroplasty. J Bone Joint Surg Am 2021; 103:1652-1662. [PMID: 34232932 DOI: 10.2106/jbjs.19.01423] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
➤ Multimodal analgesia has become the standard of care for total joint arthroplasty as it provides superior analgesia with fewer side effects than opioid-only protocols. ➤ Systemic medications, including nonsteroidal anti-inflammatory drugs, acetaminophen, corticosteroids, and gabapentinoids, and local anesthetics via local infiltration analgesia and peripheral nerve blocks, are the foundation of multimodal analgesia in total joint arthroplasty. ➤ Ideally, multimodal analgesia should begin preoperatively and continue throughout the perioperative period and beyond discharge. ➤ There is insufficient evidence to support the routine use of intravenous acetaminophen or liposomal bupivacaine as part of multimodal analgesia protocols.
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Affiliation(s)
- Joseph A Karam
- Department of Orthopaedic Surgery, University of Illinois at Chicago, Chicago, Illinois
| | - Eric S Schwenk
- Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Javad Parvizi
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
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13
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Panzenbeck P, von Keudell A, Joshi GP, Xu CX, Vlassakov K, Schreiber KL, Rathmell JP, Lirk P. Procedure-specific acute pain trajectory after elective total hip arthroplasty: systematic review and data synthesis. Br J Anaesth 2021; 127:110-132. [PMID: 34147158 DOI: 10.1016/j.bja.2021.02.036] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 01/25/2021] [Accepted: 02/23/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND For most procedures, there is insufficient evidence to guide clinicians in the optimal timing of advanced analgesic methods, which should be based on the expected time course of acute postoperative pain severity and aimed at time points where basic analgesia has proven insufficient. METHODS We conducted a systematic search of the literature of analgesic trials for total hip arthroplasty (THA), extracting and pooling pain scores across studies, weighted for study size. Patients were grouped according to basic anaesthetic method used (general, spinal), and adjuvant analgesic interventions such as nerve blocks, local infiltration analgesia, and multimodal analgesia. Special consideration was given to high-risk populations such as chronic pain or opioid-dependent patients. RESULTS We identified and analysed 71 trials with 5973 patients and constructed pain trajectories from the available pain scores. In most patients undergoing THA under general anaesthesia on a basic analgesic regimen, postoperative acute pain recedes to a mild level (<4/10) by 4 h after surgery. We note substantial variability in pain intensity even in patients subjected to similar analgesic regimens. Chronic pain or opioid-dependent patients were most often actively excluded from studies, and never analysed separately. CONCLUSIONS We have demonstrated that it is feasible to construct procedure-specific pain curves to guide clinicians on the timing of advanced analgesic measures. Acute intense postoperative pain after THA should have resolved by 4-6 h after surgery in most patients. However, there is a substantial gap in knowledge on the management of patients with chronic pain and opioid-dependent patients.
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Affiliation(s)
- Paul Panzenbeck
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Arvind von Keudell
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Girish P Joshi
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, RX, USA
| | - Claire X Xu
- Department of Anesthesiology, Pain and Critical Care Medicine, Beth Israel Deaconess Hospital, Harvard Medical School, Boston, MA, USA
| | - Kamen Vlassakov
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Kristin L Schreiber
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - James P Rathmell
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Philipp Lirk
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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Anger M, Valovska T, Beloeil H, Lirk P, Joshi GP, Van de Velde M, Raeder J. PROSPECT guideline for total hip arthroplasty: a systematic review and procedure-specific postoperative pain management recommendations. Anaesthesia 2021; 76:1082-1097. [PMID: 34015859 DOI: 10.1111/anae.15498] [Citation(s) in RCA: 100] [Impact Index Per Article: 33.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/03/2021] [Indexed: 12/11/2022]
Abstract
The aim of this systematic review was to develop recommendations for the management of postoperative pain after primary elective total hip arthroplasty, updating the previous procedure-specific postoperative pain management (PROSPECT) guidelines published in 2005 and updated in July 2010. Randomised controlled trials and meta-analyses published between July 2010 and December 2019 assessing postoperative pain using analgesic, anaesthetic, surgical or other interventions were identified from MEDLINE, Embase and Cochrane databases. Five hundred and twenty studies were initially identified, of which 108 randomised trials and 21 meta-analyses met the inclusion criteria. Peri-operative interventions that improved postoperative pain include: paracetamol; cyclo-oxygenase-2-selective inhibitors; non-steroidal anti-inflammatory drugs; and intravenous dexamethasone. In addition, peripheral nerve blocks (femoral nerve block; lumbar plexus block; fascia iliaca block), single-shot local infiltration analgesia, intrathecal morphine and epidural analgesia also improved pain. Limited or inconsistent evidence was found for all other approaches evaluated. Surgical and anaesthetic techniques appear to have a minor impact on postoperative pain, and thus their choice should be based on criteria other than pain. In summary, the analgesic regimen for total hip arthroplasty should include pre-operative or intra-operative paracetamol and cyclo-oxygenase-2-selective inhibitors or non-steroidal anti-inflammatory drugs, continued postoperatively with opioids used as rescue analgesics. In addition, intra-operative intravenous dexamethasone 8-10 mg is recommended. Regional analgesic techniques such as fascia iliaca block or local infiltration analgesia are recommended, especially if there are contra-indications to basic analgesics and/or in patients with high expected postoperative pain. Epidural analgesia, femoral nerve block, lumbar plexus block and gabapentinoid administration are not recommended as the adverse effects outweigh the benefits. Although intrathecal morphine 0.1 mg can be used, the PROSPECT group emphasises the risks and side-effects associated with its use and provides evidence that adequate analgesia may be achieved with basic analgesics and regional techniques without intrathecal morphine.
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Affiliation(s)
- M Anger
- Service d'Anesthésie Réanimation et Médecine Péri-opératoire, CHU Rennes, Université Rennes, Rennes, France
| | - T Valovska
- Service d'Anesthésie Réanimation et Médecine Péri-opératoire, CHU Rennes, Université Rennes, Rennes, France
| | - H Beloeil
- Department of Anesthesiology, Henry Ford Health Systems, Wayne State School of Medicine, Detroit, MI, USA
| | - P Lirk
- Department of Anesthesiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - G P Joshi
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - M Van de Velde
- Department of Cardiovascular Sciences, Katholieke Universiteit Leuven, Leuven, Belgium.,Department of Anaesthesiology, UZLeuven, Leuven, Belgium
| | - J Raeder
- Department of Anaesthesiology, Oslo University Hospital, Oslo, Norway.,Division of Clinical Medicine, Medical Faculty, University of Oslo, Oslo, Norway
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15
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Ji YD, Harris JA, Gibson LE, McKinley SK, Phitayakorn R. The Efficacy of Liposomal Bupivacaine for Opioid and Pain Reduction: A Systematic Review of Randomized Clinical Trials. J Surg Res 2021; 264:510-533. [PMID: 33862580 DOI: 10.1016/j.jss.2021.02.024] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 02/04/2021] [Accepted: 02/27/2021] [Indexed: 12/22/2022]
Abstract
Background The opioid crisis has prompted surgeons to search for alternative postoperative methods of analgesia. Liposomal bupivacaine is a long-acting local anesthetic formulation used for pain, potentially reducing opioid use. Evaluation of liposomal bupivacaine as a viable alternative for pain management is needed. The objective was to assess the efficacy of randomized clinical trials (RCTs) of liposomal bupivacaine in postoperative pain management and opioid consumption. Material and Methods The authors extracted RCTs comparing liposomal bupivacaine versus placebo or active comparators for postoperative pain or opioid reduction from PubMED/MEDLINE, Cochrane Library, and ClinicalTrials.gov. Exclusion criteria included nonhuman studies, non-RCTs, pooled studies, and inability to access full text. The following variables were abstracted: surgical specialty, number of subjects, pain and opioid outcomes, and authors' financial conflicts of interest. Results We identified 77 published RCTs, of which 63 studies with a total of 6770 subjects met inclusion criteria. Liposomal bupivacaine did not demonstrate significant pain relief compared to placebo or active agents in 74.58% of RCTs. Of the studies evaluating narcotic use, liposomal bupivacaine did not show a reduction in opioid consumption in 85.71% of RCTs. Liposomal bupivacaine, when compared to standard bupivacaine or another active agent, yielded no reduction in opioid use in 83.33% and 100.00% of studies, respectively. Clinical trials with a financial conflict of interest relating to the manufacturer of liposomal bupivacaine were significantly more likely to show pain relief (OR: 14.31 [95% CI, 2.8, 73.10], P = 0.0001) and decreased opioid consumption (OR: 12.35 [95% CI 1.40, 109.07], P = 0.0237). Of the 265 unpublished RCTs on ClinicalTrials.gov, 47.54% were withdrawn, terminated, suspended, or completed without study results available. Conclusions The efficacy of liposomal bupivacaine for providing superior postoperative pain control relative to placebo or another active agent is not supported by a majority of RCTs. Underreporting of trial results and bias due to underlying financial relationships amongst authors are two major concerns that should be considered when evaluating the available evidence.
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Affiliation(s)
| | | | - Lauren E Gibson
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA
| | | | - Roy Phitayakorn
- Harvard Medical School, General and Endocrine Surgery, Massachusetts General Hospital, Boston, MA
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16
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Dinges HC, Wiesmann T, Otremba B, Wulf H, Eberhart LH, Schubert AK. The analgesic efficacy of liposomal bupivacaine compared with bupivacaine hydrochloride for the prevention of postoperative pain: a systematic review and meta-analysis with trial sequential analysis. Reg Anesth Pain Med 2021; 46:490-498. [PMID: 33837139 DOI: 10.1136/rapm-2020-102427] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 03/04/2021] [Accepted: 03/04/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND/IMPORTANCE Liposomal bupivacaine (LB) is a prolonged release formulation of conventional bupivacaine designed for prolonging local or peripheral regional single injection anesthesia. To this day, the benefit of the new substance on relevant end points is discussed controversial. OBJECTIVE The objective was to determine whether there is a difference in postoperative pain scores and morphine consumption between patients treated with LB and bupivacaine hydrochloride in a systematic review and meta-analysis. EVIDENCE REVIEW Randomized controlled trials (RCT) were identified in Embase, CENTRAL, MEDLINE and Web of Science up to May 2020. Risk of bias was assessed using Cochrane methodology. Primary end points were the mean pain score difference and the relative morphine equivalent (MEQ) consumption expressed as the ratio of means (ROM) 24 and 72 hours postoperatively. FINDINGS 23 RCTs including 1867 patients were eligible for meta-analysis. The mean pain score difference at 24 hours postoperatively was significantly lower in the LB group, at -0.37 (95% CI -0.56 to -0.19). The relative MEQ consumption after 24 hours was also significantly lower in the LB group, at 0.85 (0.82 to 0.89). At 72 hours, the pain score difference was not significant at -0.25 (-0.71 to 0.20) and the MEQ ratio was 0.85 (0.77 to 0.95). CONCLUSION The beneficial effect on pain scores and opioid consumption was small but not clinically relevant, despite statistical significance. The effect was stable among all studies, indicating that it is independent of the application modality.
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Affiliation(s)
- Hanns-Christian Dinges
- Anesthesiology and Intensive Care Medicine, University Hospital of Giessen and Marburg Campus Marburg, Marburg, Hessen, Germany
| | - Thomas Wiesmann
- Anesthesiology and Intensive Care Medicine, University Hospital of Giessen and Marburg Campus Marburg, Marburg, Hessen, Germany
| | - Berit Otremba
- Anesthesiology and Intensive Care Medicine, University Hospital of Giessen and Marburg Campus Marburg, Marburg, Hessen, Germany
| | - Hinnerk Wulf
- Anesthesiology and Intensive Care Medicine, University Hospital of Giessen and Marburg Campus Marburg, Marburg, Hessen, Germany
| | - Leopold H Eberhart
- Anesthesiology and Intensive Care Medicine, University Hospital of Giessen and Marburg Campus Marburg, Marburg, Hessen, Germany
| | - Ann-Kristin Schubert
- Anesthesiology and Intensive Care Medicine, University Hospital of Giessen and Marburg Campus Marburg, Marburg, Hessen, Germany
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17
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Perineural Liposomal Bupivacaine Is Not Superior to Nonliposomal Bupivacaine for Peripheral Nerve Block Analgesia. Anesthesiology 2021; 134:147-164. [PMID: 33372953 DOI: 10.1097/aln.0000000000003651] [Citation(s) in RCA: 83] [Impact Index Per Article: 27.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Liposomal bupivacaine is purported to extend analgesia of peripheral nerve blocks when administered perineurally. However, evidence of the clinical effectiveness of perineural liposomal bupivacaine is mixed. This meta-analysis seeks to evaluate the effectiveness of perineural liposomal bupivacaine in improving peripheral nerve block analgesia as compared with nonliposomal local anesthetics. METHODS The authors identified randomized trials evaluating the effectiveness of peripheral nerve block analgesic that compared liposomal bupivacaine with nonliposomal local anesthetics. The primary outcome was the difference in area under the receiver operating characteristics curve (AUC) of the pooled 24- to 72-h rest pain severity scores. Secondary outcomes included postoperative analgesic consumption, time to first analgesic request, incidence of opioid-related side effects, patient satisfaction, length of hospital stay, liposomal bupivacaine side effects, and functional recovery. AUC pain scores were interpreted in light of a minimal clinically important difference of 2.0 cm · h. RESULTS Nine trials (619 patients) were analyzed. When all trials were pooled, AUC pain scores ± SD at 24 to 72 h were 7.6 ± 4.9 cm · h and 6.6 ± 4.6 cm · h for nonliposomal and liposomal bupivacaine, respectively. As such, perineural liposomal bupivacaine provided a clinically unimportant benefit by improving the AUC (95% CI) of 24- to 72-h pain scores by 1.0 cm · h (0.5 to 1.6; P = 0.003) compared with nonliposomal bupivacaine. Excluding an industry-sponsored trial rendered the difference between the groups nonsignificant (0.7 cm · h [-0.1 to 1.5]; P = 0.100). Secondary outcome analysis did not uncover any additional benefits to liposomal bupivacaine in pain severity at individual timepoints up to 72 h, analgesic consumption, time to first analgesic request, opioid-related side effects, patient satisfaction, length of hospital stay, and functional recovery. No liposomal bupivacaine side effects were reported. CONCLUSIONS Perineural liposomal bupivacaine provided a statistically significant but clinically unimportant improvement in the AUC of postoperative pain scores compared with plain local anesthetic. Furthermore, this benefit was rendered nonsignificant after excluding an industry-sponsored trial, and liposomal bupivacaine was found to be not different from plain local anesthetics for postoperative pain and all other analgesic and functional outcomes. High-quality evidence does not support the use of perineural liposomal bupivacaine over nonliposomal bupivacaine for peripheral nerve blocks. EDITOR’S PERSPECTIVE
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18
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Clinical Effectiveness of Liposomal Bupivacaine Administered by Infiltration or Peripheral Nerve Block to Treat Postoperative Pain. Anesthesiology 2021; 134:283-344. [PMID: 33372949 DOI: 10.1097/aln.0000000000003630] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
The authors provide a comprehensive summary of all randomized, controlled trials (n = 76) involving the clinical administration of liposomal bupivacaine (Exparel; Pacira Pharmaceuticals, USA) to control postoperative pain that are currently published. When infiltrated surgically and compared with unencapsulated bupivacaine or ropivacaine, only 11% of trials (4 of 36) reported a clinically relevant and statistically significant improvement in the primary outcome favoring liposomal bupivacaine. Ninety-two percent of trials (11 of 12) suggested a peripheral nerve block with unencapsulated bupivacaine provides superior analgesia to infiltrated liposomal bupivacaine. Results were mixed for the 16 trials comparing liposomal and unencapsulated bupivacaine, both within peripheral nerve blocks. Overall, of the trials deemed at high risk for bias, 84% (16 of 19) reported statistically significant differences for their primary outcome measure(s) compared with only 14% (4 of 28) of those with a low risk of bias. The preponderance of evidence fails to support the routine use of liposomal bupivacaine over standard local anesthetics.
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19
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Vajapey SP, Morris J, Li D, Greco NG, Li M, Spitzer AI. Outcome Reporting Patterns in Total Hip Arthroplasty. JBJS Rev 2020; 8:e0197. [DOI: 10.2106/jbjs.rvw.19.00197] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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20
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Buzin S, Gianakos AL, Li D, Viola A, Elkattawy S, Keller DM, Yoon RS, Liporace FA. Risk factors for liposomal bupivacaine resistance after total hip or knee arthroplasties: a retrospective observational cohort in 237 patients. Patient Saf Surg 2020; 14:6. [PMID: 32015758 PMCID: PMC6990520 DOI: 10.1186/s13037-020-0230-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 01/20/2020] [Indexed: 11/24/2022] Open
Abstract
Purpose Liposomal bupivacaine demonstrated promise decreasing postoperative pain in total hip and total knee arthroplasty (THA/TKA). Some randomized trials have shown non-superior results; however, confounding variables were not accounted for in such analyses. This study attempts to determine risk factors associated with failure of pain management in patients receiving liposomal bupivacaine. Methods Postoperative pain scores were collected following primary or revision arthroplasties between January 2016 and December 2017. Retrospective analysis of institutional total joint quality and outcomes registry was screened and patients undergoing primary or revision arthroplasties who completed a multi-modal pain management including liposomal bupivacaine were included in the study. Patients with a history of infection/deviated from the institutional pain management protocol were excluded. Results A total of 237 patients were included for analysis. Younger patients less than 64 years old had significantly higher pain scores between 0 and 12 h and > 24 h. Active smokers had significantly higher pain scores between 0 and 6 h and > 24 h. Patients with a history of opioid use/pain management had significantly higher pain scores at 6-12 h and 24-48 h. Regression analysis indicated risk factors for resistance to liposomal bupivacaine are younger patients less than 64 years old, those undergoing primary THA, and patients with a history of smoking/pain management/opioid use. Conclusion We identify risk factors for resistance to liposomal bupivacaine, which include younger age less than 64 years old, history of smoking/pain management/opioid use. Future studies should use these risk factors as exclusion criteria when using liposomal bupivacaine or initiating any randomized trials regarding efficacy.
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Affiliation(s)
- Scott Buzin
- 1Division of Orthopaedic Trauma & Adult Reconstruction, Department of Orthopaedic Surgery, Jersey City Medical Center - RWJBarnabas Health, 377 Jersey Ave, Suite 280A, Jersey City, NJ 07302 USA
| | - Arianna L Gianakos
- 1Division of Orthopaedic Trauma & Adult Reconstruction, Department of Orthopaedic Surgery, Jersey City Medical Center - RWJBarnabas Health, 377 Jersey Ave, Suite 280A, Jersey City, NJ 07302 USA
| | - Deborah Li
- 2University of Miami Miller School of Medicine, 1600 NW 10th Ave #1140, Miami, FL 33136 USA
| | - Anthony Viola
- 3Philadelphia College of Osteopathic Medicine, 4190 City Ave, Suite 409, Philadelphia, PA 19131 USA
| | - Sherif Elkattawy
- 1Division of Orthopaedic Trauma & Adult Reconstruction, Department of Orthopaedic Surgery, Jersey City Medical Center - RWJBarnabas Health, 377 Jersey Ave, Suite 280A, Jersey City, NJ 07302 USA
| | - David M Keller
- 1Division of Orthopaedic Trauma & Adult Reconstruction, Department of Orthopaedic Surgery, Jersey City Medical Center - RWJBarnabas Health, 377 Jersey Ave, Suite 280A, Jersey City, NJ 07302 USA
| | - Richard S Yoon
- 1Division of Orthopaedic Trauma & Adult Reconstruction, Department of Orthopaedic Surgery, Jersey City Medical Center - RWJBarnabas Health, 377 Jersey Ave, Suite 280A, Jersey City, NJ 07302 USA
| | - Frank A Liporace
- 1Division of Orthopaedic Trauma & Adult Reconstruction, Department of Orthopaedic Surgery, Jersey City Medical Center - RWJBarnabas Health, 377 Jersey Ave, Suite 280A, Jersey City, NJ 07302 USA
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21
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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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22
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Zhao B, Ma X, Zhang J, Ma J, Cao Q. The efficacy of local liposomal bupivacaine infiltration on pain and recovery after Total Joint Arthroplasty: A systematic review and meta-analysis of randomized controlled trials. Medicine (Baltimore) 2019; 98:e14092. [PMID: 30653126 PMCID: PMC6370122 DOI: 10.1097/md.0000000000014092] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 12/18/2018] [Accepted: 12/19/2018] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Total Joint Arthroplasty (TJA) is gradually emerging as the treatment of choice for end-stage osteoarthritis. In the past, Perioperative liposomal bupivacaine treatment is still a controversial subject in TJA. Therefore, we write this systematic review and meta-analysis to evaluate the efficacy of liposomal bupivacaine on pain and recovery after TJA. MATERIALS AND METHODS Embase, Pubmed, and Cochrane Library were comprehensively searched. Randomized controlled trials (RCTs), cohort studies were included in our meta-analysis. Twelve studies that compared liposomal bupivacaine groups with placebo groups were included in our meta-analysis. The research was reported according to the preferred reporting items for systematic reviews and meta-analysis (PRISMA) guidelines. RCTs were included in our meta-analysis. RESULTS Our study demonstrated that liposomal bupivacaine group was as effective as the placebo group in term of VAS score at 24 h (P = .09), 48 h (P = .97); Postoperative nausea (P = .72); and LOS (0.27). There was significant difference in terms of total morphine consumption at 24 h (P < .0001), 48 h (P = .0008). CONCLUSION Our meta-analysis demonstrated that liposomal bupivacaine has similar pain control and functional recovery after TJA which compared with the control group. However, we still need large sample size, high-quality studies to explore the relationship between complications and dose response to give the final conclusion.
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Affiliation(s)
| | - Xinlong Ma
- Biomechanics Labs of Orthopaedics Institute, Tianjin Hospital, Tianjin, People's Republic of China
| | - Jinli Zhang
- Trauma knee department 1, Tianjin Hospital, Tianjin
| | - Jianxiong Ma
- Biomechanics Labs of Orthopaedics Institute, Tianjin Hospital, Tianjin, People's Republic of China
| | - Qing Cao
- Trauma knee department 1, Tianjin Hospital, Tianjin
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Chung AS, Spangehl MJ. Peripheral Nerve Blocks vs Periarticular Injections in Total Knee Arthroplasty. J Arthroplasty 2018; 33:3383-3388. [PMID: 30197218 DOI: 10.1016/j.arth.2018.08.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 08/02/2018] [Indexed: 02/01/2023] Open
Abstract
In patients undergoing surgery, optimal pain management is associated with improved perioperative outcomes, patient satisfaction with surgery, and a more rapid functional recovery. In recent years, the employment of multimodal pain management strategies has become increasingly widespread. In particular, there has been an explosion in the use of peripheral nerve blockade and periarticular injections in total knee arthroplasty. However, there is significant variability in the administration of either modality of anesthesia. As such, a critical evaluation of the current literature is warranted to elucidate the advantages and disadvantages of each technique with the ultimate goal of further refining current pain control strategies. In this symposium, we review each of these modalities and their association with pain management, narcotic consumption, length of hospital stay, and adverse events.
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Affiliation(s)
- Andrew S Chung
- Department of Orthopaedic Surgery, Mayo Clinic, Phoenix, Arizona
| | - Mark J Spangehl
- Department of Orthopaedic Surgery, Mayo Clinic, Phoenix, Arizona
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24
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Affiliation(s)
- Mengnai Li
- The Ohio State University, Columbus, Ohio
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25
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CORR Insights®: No Clinically Important Difference in Pain Scores After THA Between Periarticular Analgesic Injection and Placebo: A Randomized Trial. Clin Orthop Relat Res 2018; 476:1846-1847. [PMID: 30024466 PMCID: PMC6259791 DOI: 10.1097/corr.0000000000000401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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26
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Infiltration Techniques for Local Infiltration Analgesia With Liposomal Bupivacaine in Extracapsular and Intracapsular Hip Fracture Surgery: Expert Panel Opinion. J Orthop Trauma 2018; 32 Suppl 2:S5-S10. [PMID: 30028758 DOI: 10.1097/bot.0000000000001227] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Liposomal bupivacaine (LB) has demonstrated efficacy in improving pain scores and reducing opioid consumption across a variety of surgical settings, including orthopaedic surgery. However, meticulous infiltration techniques combined with a multimodal approach are important to optimizing outcomes. METHODS A panel of 4 orthopaedic surgeons and 3 anesthesiologists convened on April 1, 2017, to discuss current practices and develop a consensus statement regarding local infiltration analgesia with LB for extracapsular and intracapsular hip fracture surgery, including LB infiltration techniques. RESULTS Optimizing surgical outcomes with LB in hip fracture surgery requires an understanding of the neuroanatomy of the surgical site and the pharmacology of the drug. Meticulous infiltration technique is critical to achieve optimal results with LB given its viscosity and reduced diffusion compared with bupivacaine HCl. For extracapsular procedures, a total injection volume of 120 mL is recommended, whereas intracapsular procedures typically require a lower volume (∼80 mL). In both cases, infiltration is best achieved using a 22-gauge needle and applying a tracking and/or fanning technique. To ensure optimal placement, LB should be infiltrated using multiple, small-volume (1- to 5-mL) injections spaced at 1.0-cm intervals. CONCLUSIONS These consensus recommendations regarding LB infiltration techniques can serve as a resource for designing clinical studies to evaluate outcomes using periarticular infiltration of LB in extracapsular and intracapsular hip fracture surgery as part of a multimodal pain management approach. LEVEL OF EVIDENCE Level V.
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