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Chen Y, Xu J, Li P, Shi L, Zhang S, Guo Q, Yang Y. Advances in the use of local anesthetic extended-release systems in pain management. Drug Deliv 2024; 31:2296349. [PMID: 38130151 PMCID: PMC10763865 DOI: 10.1080/10717544.2023.2296349] [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: 07/13/2023] [Accepted: 11/15/2023] [Indexed: 12/23/2023] Open
Abstract
Pain management remains among the most common and largely unmet clinical problems today. Local anesthetics play an indispensable role in pain management. The main limitation of traditional local anesthetics is the limited duration of a single injection. To address this problem, catheters are often placed or combined with other drugs in clinical practice to increase the time that local anesthetics act. However, this method does not meet the needs of clinical analgesics. Therefore, many researchers have worked to develop local anesthetic extended-release types that can be administered in a single dose. In recent years, drug extended-release systems have emerged dramatically due to their long duration and efficacy, providing more possibilities for the application of local anesthetics. This paper summarizes the types of local anesthetic drug delivery systems and their clinical applications, discusses them in the context of relevant studies on local anesthetics, and provides a summary and outlook on the development of local anesthetic extended-release agents.
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Affiliation(s)
- Yulu Chen
- Department of Anesthesiology, Xiangya Hospital, Central South University, Changsha, China
| | - Jingmei Xu
- Department of Anesthesiology, Xiangya Hospital, Central South University, Changsha, China
| | - Ping Li
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
- Department of Obstetrics, Xiangya Hospital, Central South University, Changsha, China
| | - Liyang Shi
- College of Biology, Hunan University, Changsha, China
| | - Sha Zhang
- Department of Anesthesiology, Xiangya Hospital, Central South University, Changsha, China
| | - Qulian Guo
- Department of Anesthesiology, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Yong Yang
- Department of Anesthesiology, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
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Marciniak D, Raymond D, Alfirevic A, Yalcin EK, Bakal O, Pu X, Kelava M, Duncan A, Hargrave J, Bauer A, Bustamante S, Lam L, Murthy S, Sessler DI, Turan A. Combined pectoralis and serratus anterior plane blocks with or without liposomal bupivacaine for minimally invasive thoracic surgery: A randomized clinical trial. J Clin Anesth 2024; 97:111550. [PMID: 39029153 DOI: 10.1016/j.jclinane.2024.111550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Revised: 06/13/2024] [Accepted: 07/08/2024] [Indexed: 07/21/2024]
Abstract
BACKGROUND Minimally invasive thoracic surgery is associated with substantial pain that can impair pulmonary function. Fascial plane blocks may offer a favorable alternative to opioids, but conventional local anesthetics provide a limited duration of analgesia. We therefore tested the primary hypothesis that a mixture of liposomal bupivacaine and plain bupivacaine improves the overall benefit of analgesia score (OBAS) during the first three postoperative days compared to bupivacaine alone. Secondarily, we tested the hypotheses that liposomal bupivacaine improves respiratory mechanics, and decreases opioid consumption. METHODS Adults scheduled for robotically or video-assisted thoracic surgery with combined ultrasound-guided pectoralis II and serratus anterior plane block were randomized to bupivacaine or bupivacaine combined with liposomal bupivacaine. OBAS was measured on postoperative days 1-3 and was analyzed with a linear mixed regression model. Postoperative respiratory mechanics were estimated using a linear mixed model. Total opioid consumption was estimated with a simple linear regression model. RESULTS We analyzed 189 patients, of whom 95 were randomized to the treatment group and 94 to the control group. There was no significant treatment effect on total OBAS during the initial three postoperative days, with an estimated geometric mean ratio of 0.93 (95% CI: 0.76, 1.14; p = 0.485). There was no observed treatment effect on respiratory mechanics, total opioid consumption, or pain scores. Average pain scores were low in both groups. CONCLUSIONS Liposomal bupivacaine did not improve OBAS during the initial postoperative three days following minimally invasive thoracic procedures. Furthermore, there was no improvement in respiratory mechanics, no reduction in opioid consumption, and no decrease in pain scores. Thus, the data presented here does not support the use of liposomal bupivacaine over standard bupivacaine to enhance analgesia after minimally invasive thoracic surgery. SUMMARY STATEMENT For minimally invasive thoracic procedures, addition of liposomal bupivacaine to plain bupivacaine for thoracic fascial plane blocks does not improve OBAS, reduce opioid requirements, improve postoperative respiratory mechanics, or decrease pain scores.
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Affiliation(s)
- Donn Marciniak
- Department of Cardiothoracic Anesthesiology, Cleveland Clinic, Cleveland, OH, USA.
| | - Daniel Raymond
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Andrej Alfirevic
- Department of Cardiothoracic Anesthesiology, Cleveland Clinic, Cleveland, OH, USA
| | - Esra Kutlu Yalcin
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA; Department of General Anesthesiology, Cleveland Clinic, Cleveland, OH, USA
| | - Omer Bakal
- Department of Anesthesiology, UT Health San Antonio, San Antonio, TX, USA
| | - Xuan Pu
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA; Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Marta Kelava
- Department of Cardiothoracic Anesthesiology, Cleveland Clinic, Cleveland, OH, USA
| | - Andra Duncan
- Department of Cardiothoracic Anesthesiology, Cleveland Clinic, Cleveland, OH, USA
| | - Jennifer Hargrave
- Department of Cardiothoracic Anesthesiology, Cleveland Clinic, Cleveland, OH, USA
| | - Andrew Bauer
- Department of Cardiothoracic Anesthesiology, Cleveland Clinic, Cleveland, OH, USA
| | - Sergio Bustamante
- Department of Cardiothoracic Anesthesiology, Cleveland Clinic, Cleveland, OH, USA
| | - Louis Lam
- Department of Pulmonary Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Sudish Murthy
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Daniel I Sessler
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
| | - Alparslan Turan
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA; Department of General Anesthesiology, Cleveland Clinic, Cleveland, OH, USA
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Zhang W, Li C, Zhao C, Ji N, Luo F. Pre-incisional infiltration with ropivacaine plus dexamethasone palmitate emulsion for postoperative pain in patients undergoing craniotomy: study protocol for a prospective, randomized controlled trial. Trials 2022; 23:996. [PMID: 36510271 PMCID: PMC9743637 DOI: 10.1186/s13063-022-06936-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 11/15/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Post-craniotomy pain is a common occurrence which is associated with poor outcomes. Pre-emptive scalp infiltration with dexamethasone and ropivacaine has been proven effective in previous studies but with limited clinical significance. Dexamethasone palmitate emulsion (D-PAL) is a pro-drug incorporating dexamethasone into lipid microspheres with greater anti-inflammatory activity and fewer side effects than free dexamethasone. However, its effects in post-craniotomy pain management remain unknown. This study hypothesizes that pre-emptive scalp infiltration with ropivacaine plus D-PAL emulsion can achieve superior analgesic effects to ropivacaine alone in adult patients undergoing craniotomy. METHODS/DESIGN This is a single center, randomized controlled trial enrolling 130 patients scheduled for supratentorial craniotomy, which is expected to last longer than 4 h. We compare the efficacy and safety for postoperative pain relief of ropivacaine plus D-PAL group and ropivacaine alone group following pre-emptive scalp infiltration. Primary outcome will be pain Numerical Rating Scale at 24 h postoperatively. Secondary outcomes will include further analgesia evaluations and drug-related complications within a follow-up period of 3 months. DISCUSSION This is the first randomized controlled trial aiming to assess the possible benefits or disadvantages of D-PAL emulsion for incisional pain in craniotomy. It may provide an alternative to optimize pain outcome for neurosurgical patients. TRIAL REGISTRATION ClinicalTrials.gov (NCT04488315). Registered on 19 July 2020.
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Affiliation(s)
- Wei Zhang
- grid.24696.3f0000 0004 0369 153XDepartment of Day Surgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070 People’s Republic of China
| | - Chunzhao Li
- grid.24696.3f0000 0004 0369 153XDepartment of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, 100070 Beijing, People’s Republic of China
| | - Chunmei Zhao
- grid.24696.3f0000 0004 0369 153XDepartment of Day Surgery and Pain Management, Beijing Tiantan Hospital, Capital Medical University, 100070 Beijing, People’s Republic of China
| | - Nan Ji
- grid.24696.3f0000 0004 0369 153XDepartment of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, 100070 Beijing, People’s Republic of China
| | - Fang Luo
- grid.24696.3f0000 0004 0369 153XDepartment of Day Surgery and Pain Management, Beijing Tiantan Hospital, Capital Medical University, 100070 Beijing, People’s Republic of China
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Patel KM, de Guzman K, Wise J, van Helmond N, Krishnan S, Mitrev LV, Trivedi KC, Shersher D, Bowen F, Desai RG. Serratus Anterior Plane Block Versus Intercostal Nerve Blocks in Thoracic Surgery: A Retrospective Analysis. J Cardiothorac Vasc Anesth 2022; 36:2841-2842. [PMID: 35365373 DOI: 10.1053/j.jvca.2022.02.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 02/22/2022] [Accepted: 02/27/2022] [Indexed: 11/11/2022]
Affiliation(s)
- Kinjal M Patel
- Department of Anesthesiology, Cooper Medical School of Rowan University, Cooper University Health Care, Camden, NJ.
| | | | - Julie Wise
- Department of Anesthesiology, Robert Wood Johnson Medical Center, New Brunswick, NJ
| | - Noud van Helmond
- Department of Anesthesiology, Cooper Medical School of Rowan University, Cooper University Health Care, Camden, NJ
| | - Sandeep Krishnan
- Adult Cardiothoracic Anesthesiology, Wayne State University School of Medicine, Pontiac, MI
| | - Ludmil V Mitrev
- Department of Anesthesiology, Cooper Medical School of Rowan University, Cooper University Health Care, Camden, NJ
| | - Keyur C Trivedi
- Department of Anesthesiology, Cooper Medical School of Rowan University, Cooper University Health Care, Camden, NJ
| | - David Shersher
- Department of Thoracic Surgery, Cooper Medical School of Rowan University, Cooper University Health Care, Camden, NJ
| | - Frank Bowen
- Department of Thoracic Surgery, Cooper Medical School of Rowan University, Cooper University Health Care, Camden, NJ
| | - Ronak G Desai
- Department of Anesthesiology, Cooper Medical School of Rowan University, Cooper University Health Care, Camden, NJ
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Hamilton C, Alfille P, Mountjoy J, Bao X. Regional anesthesia and acute perioperative pain management in thoracic surgery: a narrative review. J Thorac Dis 2022; 14:2276-2296. [PMID: 35813725 PMCID: PMC9264080 DOI: 10.21037/jtd-21-1740] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 03/24/2022] [Indexed: 12/11/2022]
Abstract
Background and Objective Thoracic surgery causes significant pain which can negatively affect pulmonary function and increase risk of postoperative complications. Effective analgesia is important to reduce splinting and atelectasis. Systemic opioids and thoracic epidural analgesia (TEA) have been used for decades and are effective at treating acute post-thoracotomy pain, although both have risks and adverse effects. The advancement of thoracoscopic surgery, a focus on multimodal and opioid-sparing analgesics, and the development of ultrasound-guided regional anesthesia techniques have greatly expanded the options for acute pain management after thoracic surgery. Despite the expansion of surgical techniques and analgesic approaches, there is no clear optimal approach to pain management. This review aims to summarize the body of literature regarding systemic and regional anesthetic techniques for thoracic surgery in both thoracotomy and minimally invasive approaches, with a goal of providing a foundation for providers to make individualized decisions for patients depending on surgical approach and patient factors, and to discuss avenues for future research. Methods We searched PubMed and Google Scholar databases from inception to May 2021 using the terms “thoracic surgery”, “thoracic surgery AND pain management”, “thoracic surgery AND analgesia”, “thoracic surgery AND regional anesthesia”, “thoracic surgery AND epidural”. We considered articles written in English and available to the reader. Key Content and Findings There is a wide variety of strategies for treating acute pain after thoracic surgery, including multimodal opioid and non-opioid systemic analgesics, regional anesthesia including TEA and paravertebral blocks (PVB), and a recent expansion in the use of novel fascial plane blocks especially for thoracoscopy. The body of literature on the effectiveness of different approaches for thoracotomy and thoracoscopy is a rapidly expanding field and area of active debate. Conclusions The optimal analgesic approach for thoracic surgery may depend on patient factors, surgical factors, and institutional factors. Although TEA may provide optimal analgesia after thoracotomy, PVB and emerging fascial plane blocks may offer effective alternatives. A tailored approach using multimodal systemic therapies and regional anesthesia is important, and future studies comparing techniques are necessary to further investigate the optimal approach to improve patient outcomes.
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Affiliation(s)
- Casey Hamilton
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Paul Alfille
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Jeremi Mountjoy
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Xiaodong Bao
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
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Pai P, Hong J, Phillips A, Lin HM, Lai YH. Serratus Anterior Plane Block Versus Intercostal Block with Incision Infiltration in Robotic-Assisted Thoracoscopic Surgery: A Randomized Controlled Pilot Trial. J Cardiothorac Vasc Anesth 2021; 36:2287-2294. [PMID: 34819261 DOI: 10.1053/j.jvca.2021.10.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 10/07/2021] [Accepted: 10/15/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Patients undergoing robotic video-assisted thoracoscopic surgery (rVATS) report significant postoperative pain. Both the serratus anterior plane block (SAPB) and the surgical intercostal block (IB) (performed by a surgeon from within the thorax), along with incision infiltration (II), are distinct modalities that target the lateral cutaneous branches of intercostal nerves and are acceptable analgesic modalities in an enhanced recovery after rVATS surgery. DESIGN Prospective, double-blinded, randomized, controlled pilot trial with 65 patients to assess the difference in analgesia quality between the SAPB and IB+II in rVATS. SETTING Major academic teaching hospital. PARTICIPANTS The inclusion criteria included ASA physical status I-IV, ages 18-to-75 undergoing an elective, unilateral rVATS procedure. INTERVENTIONS Patients were randomized to receive either an ultrasound-guided SAPB at the end of their surgery, using a 20-mL mixture consisting of 10 mL of liposomal bupivacaine (133 mg) and 10 mL 0.25% bupivacaine, or IB+II, using a 20-mL mixture consisting of 10 mL of liposomal bupivacaine (133 mg) and 10 mL 0.5% bupivacaine prior to skin closure by the surgeon. RESULTS The primary outcome was the amount of postoperative opioid consumption in morphine milliequivalents [MME] during the first 24 hours after surgery. Secondary outcomes were time to first analgesic request, VAS scores at zero, two, six, 18, or 24 hours at rest, and PACU, ICU, or hospital lengths of stay (LOS). There were no differences in any outcomes between the groups. CONCLUSIONS Both SAPB and IB+II are comparable analgesic modalities for rVATS procedures.
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Affiliation(s)
- Poonam Pai
- Mount Sinai West - Morningside Hospitals, Department of Anesthesiology, Perioperative and Pain Medicine, New York, USA.
| | - Janet Hong
- Mount Sinai West - Morningside Hospitals, Department of Anesthesiology, Perioperative and Pain Medicine, New York, USA.
| | - Annmarie Phillips
- Mount Sinai West - Morningside Hospitals, Department of Anesthesiology, Perioperative and Pain Medicine, New York, USA.
| | - Hung-Mo Lin
- Icahn School of Medicine at Mount Sinai, Department of Anesthesiology, Perioperative and Pain Medicine, New York, USA.
| | - Yan H Lai
- Mount Sinai West - Morningside Hospitals, Department of Anesthesiology, Perioperative and Pain Medicine, New York, USA.
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Liposomal Bupivacaine to Treat Postoperative Pain: Comment. Anesthesiology 2021; 135:762-763. [PMID: 34259799 DOI: 10.1097/aln.0000000000003882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Campos JH, Seering M. A Provocative Dilemma: Liposomal Bupivacaine Versus Bupivacaine With Epinephrine for Intercostal Nerve Blocks With Enhanced Recovery During Robotic Thoracic Surgery. J Cardiothorac Vasc Anesth 2021; 35:2294-2296. [PMID: 33975793 DOI: 10.1053/j.jvca.2021.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 04/05/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Javier H Campos
- Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, Iowa.
| | - Melinda Seering
- Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, Iowa
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Campos JH, Seering M. Does Liposomal Bupivacaine Have Any Advantage Over Bupivacaine Hydrochloride for Intercostal Nerve Blocks in Minimally Invasive Thoracic Surgery? J Cardiothorac Vasc Anesth 2021; 35:1399-1403. [PMID: 33563528 DOI: 10.1053/j.jvca.2021.01.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 01/15/2021] [Indexed: 01/16/2023]
Affiliation(s)
- Javier H Campos
- Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Melinda Seering
- Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, IA
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