Local anaesthetic infusion for postoperative pain

A Review of Wound Infusion With Local Anesthetics in Plastic Surgery

BACKGROUND

Suboptimal pain management is a common, yet largely unrecognized, problem in the postsurgical patient population. Current treatment protocols heavily rely on opioid use and, though generally effective in providing pain relief, are associated with multiple side effects. The present systematic review aims to offer plastic surgeons insight into the current state of literature on prolonged local anesthetic wound infusion regimens, evaluating both their efficacy in lowering pain scores and the potential opioid-sparing effect.

METHODS

A comprehensive literature search of the Medline, Embase, and Cochrane Library databases was performed to identify relevant studies published between 1980 and December 2017 evaluating the use of prolonged local anesthetic wound infusion for postoperative pain management in plastic surgery.

RESULTS

A total of 28 articles were selected, including 3904 patients. The overall infection rate in all patients treated with postsurgical local anesthetic wound infiltration was 0.28% (7/2536). There were no reported cases of systemic toxicity. An opioid-sparing effect was found in 92% (12/13) of studies when compared to an active comparator and 88% (7/8) of those comparing to placebo. Pain scores were decreased in 90% (9/10) of studies comparing wound infiltration to narcotic-based regimens and in 67% (6/9) of those comparing to placebo.

CONCLUSIONS

Continuous or intermittent wound infusion is safe and effective in reducing pain scores and opioid consumption in plastic surgery. Though the overall pain-lowering effect appears to be modest, ease of catheter insertion and patient satisfaction make this technique an alluring alternative to more validated approaches such as neuraxial or peripheral nerve blocks.

Management of Acute Postoperative Pain in Hand Surgery: A Systematic Review

PURPOSE

To conduct a systematic review to guide hand surgeons in an evidenced-based approach in managing postoperative pain.

METHODS

We performed a literature review for primary research articles on management of postoperative pain in hand surgery patients using Medical Literature Analysis and Retrieval System Online (MEDLINE; PubMed), Excerpta Medica database (EMBASE), and the Cochrane Collaboration Library. Inclusion criteria were primary journal articles examining treatment of acute postoperative pain based on any modality. Data related to pain assessment, postoperative recovery, and total postoperative analgesic consumption were extracted.

RESULTS

A total of 903 publications were reviewed; 184 publications underwent abstract review. After applying inclusion and exclusion criteria, 10 primary articles were selected for inclusion in this review. Data were noted to be heterogeneous and findings were compiled. Results were divided into groups evaluating postoperative pain medications or pain infusion catheters.

CONCLUSIONS

Although this review did not demonstrate a best practices model for postoperative pain management, it provides evidence for alternative medications and treatment strategies. The evidence available suggests that postoperative pain control should begin before surgery and that combining multiple strategies for pain treatment is beneficial. Given the increasing attention paid to narcotic prescriptions and the potential for abuse, surgeons should adopt evidence-based pain management practices. We provide an example algorithm for pain treatment in hand surgery based on available data and the authors' experience.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic III.

The late effect of intraoperative wound infiltration with local anaesthetic in surgical patients; is there any? A randomized control trial

INTRODUCTION

Intraoperative wound infiltration with local anaesthetic is commonly used. Apart from the obvious immediate action it has been supported that a possible down regulation of pain receptors may lead to longer effects. Our aim was to compare the use of local anaesthetic versus placebo in order to assess if indeed there is a late beneficial effect.

METHODS

We conducted an RCT involving 400 consecutive general surgery patients randomized in 2 groups: Group A = placebo, Group B = wound infiltration with 15 ml of ropivacaine 10%. We recorded the preoperative and postoperative pain for the 1st week as well as the type and quantity of the analgesia used during the study period.

RESULTS

No significant difference was found between the groups in all known confounding factors recorded. No significant difference was found in the intensity of postoperative pain. More people of group A required NSAIDs during the first 3 PO days while more people of Group B required stronger painkillers. For those patients who underwent a non urgent operation and especially laparoscopic surgery higher pain score was recorded in the group B from the 3rd PO day onwards.

DISCUSSION

Intraoperative local infiltration of the wound with local anaesthetic offers no further benefit for the general surgery apart from that of the immediate PO period. There is no late effect for pain control. Considering that during the immediate postoperative period stronger systematic painkillers are given the intraoperative, infiltration of the wound with the local anaesthetic under study offers no obvious benefit.

[Finger flexor tenolysis]

Flexor tendon adhesions in zone II are common. The origin of these adhesions is multifactorial. Flexor tenolysis consists of releasing the adhesions to restore the tendon's normal path and the patient's active range of motion. This surgery is complex and extremely delicate. It must be associated with early active mobilization. Any surgical procedure that would hamper this active mobilization must be completed before the flexor tenolysis. The patient should be informed of the risk of flexor digitorum profundus rupture, which is the main complication of this surgery.

Treatment of unfavourable results of flexor tendon surgery: Ruptured repairs, tethered repairs and pulley incompetence

As primary repair of divided flexor tendons becomes more common, secondary tendon surgery becomes largely that of the complications of primary repair, namely ruptured and adherent repairs. These occur with an incidence of each in most reported series world-wide of around 5%, with these problems having changed little in the last two decades, despite strengthening our suture repairs. Where the primary referral service is less well-developed, and as a more occasional occurrence where primary treatment is the routine, the surgeon faces different problems. Patients arrive at a hand unit variable, but longer, times after the primary insult, having had no, or bad, previous treatment. Sometimes the situation is the same, viz. an extended finger with no active flexion, but now no longer amenable to primary repair. Frequently, it is much more complex as a result of injuries to the other tissues of the digit and, also, as a result of the unaided healing process within the digit in the presence of an inactive flexor system. We present our experience in dealing with ruptured repairs, tethered repairs and pulley incompetence.

The surgical management of painful nerves of the upper limb: a unit perspective

Some patients develop excessive peripheral nerve pain beyond that normally experienced after injury or surgery. Managing this pain can be a difficult and frustrating experience for both the surgeon and patient concerned. We present a system for the classification, assessment and treatment of painful neuromas of the upper limb.

Relief of the pain of neuromas-in-continuity and scarred median and ulnar nerves in the distal forearm and wrist by neurolysis, wrapping in vascularized forearm fascial flaps and adjunctive procedures

This prospective study reports treatment by neurolysis then wrapping the nerves in vascularized forearm fascia and, when necessary, adjunctive procedures of twelve median and two ulnar nerves in continuity in the distal forearm with neurogenic pain. Preoperatively, all 14 patients had severe pain in at least one of the five modalities of pain analysed. There was complete resolution of all modalities of pain in eight of 14 patients following neurolysis and fascial nerve wrap surgery and two more patients had only mild pain in one or two modalities. After the addition of wrist pinning or arthrodesis alone or in conjunction with selective division of flexor tendons in four patients, there was complete resolution of all modalities of pain in nine of 14 patients. A further three patients had mild pain in three or less modalities and only one patient continued to have severe pain in one modality.

A Review of Pain Pumps in Plastic Surgery

Continuous infusions of local anesthetics for postoperative analgesia have been used for several years by numerous surgical subspecialties. Plastic surgery has only recently embraced these pain pumps, most of which have been used in breast and abdominal surgery. Many different pain pump systems are available. They have been used in many studies and have been found to be effective in improving postoperative analgesia, decreasing narcotic use, and decreasing nausea and vomiting. They have little associated morbidity and systemic toxicity. However, the efficacy of these pain pumps in various areas of plastic surgery need to be studied in well-designed prospective clinical trials. The present paper reviews the current status of the available evidence, usefulness and limitations of the use of pain pumps in plastic surgery.

[Postoperative analgesia with continuous intra-articular infusion of ropivacaine following trapeziectomy]

OBJECTIVES

A pilot study was implemented to evaluate the efficacy of patient controlled analgesia (PCA) with continuous intra-articular infusion of ropivacaine following trapeziectomy with ligament reconstruction and tendon interposition.

METHODS

Twelve patients were prospectively included. A catheter was placed into the trapezium void and connected to a PCA pump set on a continuous intra-articular infusion rate of ropivacaine: 2mg/ml. Patients were allowed to deliver additional boluses when analgesia was incomplete.

RESULTS

Pain was evaluated less than 3/10 (Numeric Scale Evaluation) by 92% of the patients during the first 48 h. No toxicity of the local anaesthetic nor catheter-related complication were reported.

CONCLUSION

This preliminary study showed continuous basal and bolus infusion of ropivacaine through a single catheter placed into the trapezium void to provide an excellent postoperative pain control and to be related to a high patient's satisfaction level.

Relocation of painful neuromas in Zone III of the hand and forearm

Painful nerves are a difficult and complex clinical problem. We describe the result of treatment by proximal relocation of 51 painful end neuromas and scarred nerves of the forearm in 33 patients. The relocated nerves included 29 superficial radial nerves, 16 lateral antebrachial cutaneous nerves, two medial cutaneous nerves and four posterior cutaneous nerves. These relocations achieved no, or only mild, pain in 100% of nerves at the original site and 94% of nerves at the relocation site. It also achieved no, or only mild, hypersensitivity in 96% of nerves at the original site and 98% of nerves at the relocation site. The technical difficulties encountered in this region, in particular on the radial aspect of the wrist, are discussed.

Preventing the development of chronic pain after orthopaedic surgery with preventive multimodal analgesic techniques

The prevalences of complex regional pain syndrome, phantom limb pain, chronic donor-site pain, and persistent pain following total joint arthroplasty are alarmingly high. Central nervous system plasticity that occurs in response to tissue injury may contribute to the development of persistent postoperative pain. Many researchers have focused on methods to prevent central neuroplastic changes from occurring through the utilization of preemptive or preventive multimodal analgesic techniques. Multimodal analgesia allows a reduction in the doses of individual drugs for postoperative pain and thus a lower prevalence of opioid-related adverse events. The rationale for this strategy is the achievement of sufficient analgesia due to the additive effects of, or the synergistic effects between, different analgesics. Effective multimodal analgesic techniques include the use of nonsteroidal anti-inflammatory drugs, local anesthetics, alpha-2 agonists, ketamine, alpha(2)-delta ligands, and opioids.

Relocation of neuromas of the lateral antebrachial cutaneous nerve of the forearm into the brachialis muscle

Painful neuromas following injury to the radial side of the wrist can be treated by relocation away from the zone of injury and implantation into muscle. Relocation to the brachialis muscle is useful for isolated neuromas of the lateral antebrachial cutaneous nerve and involves a shorter dissection than relocation to the brachioradialis. It is also useful in patients undergoing multiple procedures to avoid disturbing previous relocations to the brachioradialis. This paper describes the successful relocation of painful neuromas of the lateral antebrachial cutaneous nerve to the brachialis muscle in seven patients.

Relocation of painful end neuromas and scarred nerves from the zone II territory of the hand

This paper reports the results of treatment by proximal relocation of 46 painful end-neuromas or scarred nerves in 33 patients from the pre-defined Zone II of the hand. The relocated nerves included four palmar cutaneous branches of the median nerve, 17 dorsal branches of the ulnar nerves and 25 digital nerves. If no pain at the original site and no pain or only mild pain at the relocation site are considered an adequate treatment of these difficult problems, these relocation procedures achieve complete control of spontaneous baseline pain, complete control of spontaneous spikes of pain, 93% control of direct pressure pain, complete control of movement pain (excluding the extremes of movement of the wrist into extension, supination and, less frequently, pronation) and 96% control of hypersensitivity of the overlying skin.

Postoperative pathophysiology and choice of incision

In the few days following major surgical procedures, there are three main physiologic processes which are amenable to surgical management: restoration of fluid and electrolyte homeostasis, management of pain, and attention to gastrointestinal function. New information regarding optimizing the management of these processes is presented, which may accelerate recovery and give improved comfort following abdominal surgery. The type of incision used seems not to be a major factor in such recovery.

Treatment of end-neuromas, neuromas-in-continuity and scarred nerves of the digits by proximal relocation

This paper reports the results of treatment by proximal relocation of 104 painful nerves in 57 digits in 48 patients. These included 86 digital nerves and 18 terminal branches of the superficial radial nerve and the dorsal branch of the ulnar nerve. Eighty-three were end-neuromas and 14 were neuromas-in-continuity, of which nine followed nerve repair and five occurred following a closed crush injury. Seven were painful as a result of tethering in scarred tissue. Eighty nerves (77%) required a single relocation and 24 (23%) required more than one operation. Ninety-eight per cent of nerve relocations achieved complete pain relief at the primary site. One patient had mild pain on pressure at the primary site after relocation of two nerves from this site. Over 90% of the nerves had no spontaneous pain, pain on movement or hypersensitivity of the overlying skin at the final site of relocation. However, the incidence of mild or no pain on direct pressure at the site of nerve relocation was lower at 83% as relocated nerves, although traumatized less often at the sites chosen for relocation, can still be painful on direct pressure.