The analgesic efficacy of patient-controlled bupivacaine wound instillation after total abdominal hysterectomy with bilateral salpingo-oophorectomy

Assessment of the Safety and Efficiency of a Preperitoneal Continuous Infusion Using Bupivacaine after Abdominal Laparotomy in Digestive Carcinology

The purpose of this paper is to evaluate the safety and efficacy of continuous preperitoneal wound infiltration using bupivacaine after abdominal laparotomy in relation to plasma bupivacaine concentration and visual analog scale. Our study was performed on 60 adult patients with digestive cancer, operated at laparotomy, and randomized into two groups: bupivacaine and saline groups. The wound infiltration was through a multiperforated catheter along the scar. For the bupivacaine group, 0.25% bupivacaine was used; however, for the saline group, only saline (0.9%) was infiltrated. The pain was assessed by using the visual analog scale (VAS) in both groups. Plasma bupivacaine concentration was measured by high-performance liquid chromatography. The bupivacaine group had significantly lower postoperative morphine consumption and lower postoperative pain than the saline group (P < 0.0001). The majority of patients in the bupivacaine group had significant relief with the VAS scores of less than 3/10 cm at rest and 6/10 cm on mobilization. However, for the saline group, the VAS scores were higher than 6/10 cm either at rest or with mobilization. There was no clinical sign of toxicity and no technical complications for the bupivacaine group. Only eleven patients required morphine in this group, but the majority of patients received morphine at different doses in the saline group. Plasma bupivacaine was at very low concentrations. Overall, the current study has confirmed that continuous preperitoneal wound infiltration as postoperative analgesia is a simple, effective, and safe technique. It allows decreasing of morphine consumption and subsequently canceling their side effects.

Pain alleviation in patients undergoing cardiac surgery; presternal local anesthetic and magnesium infiltration versus conventional intravenous analgesia: a randomized double-blind study

Background

Magnesium is one of the effective, safe local anesthetic adjuvants that can exert an analgesic effect in conditions presenting acute and chronic post-sternotomy pain. We studied the efficacy of continuous infusion of presternal magnesium sulfate with bupivacaine for pain relief following cardiac surgery.

Methods

Ninety adult patients undergoing valve replacement cardiac surgery randomly allocated into three groups. In all patients; a presternal catheter was placed for continuous infusion of either 0.125% bupivacaine and 5% magnesium sulfate (3 ml/h for 48 hours) in group 1, or 0.125% bupivacaine only in the same rate in group 2, versus conventional intravenous paracetamol and ketorolac in group 3. Rescue analgesia was iv 25 µg fentanyl. Postoperative Visual Analog Scale (VAS) and fentanyl consumption during the early two postoperative days were assessed. All patients were followed up over two months for occurrence of chronic post-sternotomy pain.

Results

VAS values showed high significant differences during the first 48 hours with the least pain scale in group 1 and significantly least fentanyl consumption (30.8 ± 7 µg in group 1 vs. 69 ± 18 µg in group 2, and 162 ± 3 in group 3 respectively). The incidence of chronic pain has not differed between the three groups although it was more pronounced in group 3.

Conclusions

Continuous presternal bupivacaine and magnesium infusion resulted in better postoperative analgesia than both presternal bupivacaine alone or conventional analgesic groups.

Does continuous wound infiltration enhance baseline intravenous multimodal analgesia after posterior spinal fusion surgery? A randomized, double-blinded, placebo-controlled study

PURPOSE

There has been a growing interest in continuous local anaesthetic wound infiltration as a non-opioid technique for postoperative pain relief. The impact of this modality on baseline analgesia after spinal fusion surgery has however been inconclusive. We tested whether continuous wound infiltration with ropivacaine can enhance postoperative analgesia compared to a baseline intravenous multimodal analgesia protocol after spinal fusion surgery.

METHODS

In this randomized, double-blinded, placebo-controlled study, a multiholed 19-gauge catheter was placed at the end of the surgical procedure through the wound to permit the continuous administration (8 ml/h) of ropivacaine 0.2 % (ropivacaine group; n = 19 patients) or saline (control group; n = 20 patients) during the first 48 postoperative hours (H48). Both groups received intraoperative low-dose ketamine, a combination of acetaminophen, non-steroidal anti-inflammatory drug, and nefopam over the same postoperative period, and morphine delivered by a patient-controlled analgesia (PCA) device.

RESULTS

Morphine consumption was comparable between the two groups both at H48, 38 mg (26:52) (median, 25th:75th percentile) (control group) versus 43 mg (19:74) (ropivacaine group), and at H24, 18 mg (16:22) versus 22 mg (9:35) respectively. Pain scores at rest and during mobilization, quality of postoperative sleep, and morphine-related side effects were comparable between the two groups at H24 and H48.

CONCLUSION

Our findings indicate that no additional analgesia was provided with continuous wound infiltration of ropivacaine compared to a baseline intravenous multimodal analgesia protocol after spinal fusion surgery.

TRIAL REGISTRATION

Clinicaltrials.gov #NCT01743794.

Comparison of the analgesic effect between continuous wound infiltration and single-injection transversus abdominis plane block after gynecologic laparotomy

PURPOSE

Both single-injection transversus abdominis plane (TAP) block and continuous wound infiltration (CWI) provide postoperative analgesia, but no study has compared the two regional techniques. We tested the hypothesis that CWI is more effective for controlling postoperative pain compared with single-injection TAP block after laparotomy.

METHODS

We conducted a prospective randomized study of patients undergoing gynecologic laparotomy with midline incision through the umbilicus under general anesthesia. The patients were allocated to receive either single-injection TAP block (TAP group) or CWI (CWI group) for postoperative analgesia. All patients received intravenous patient-controlled analgesia with morphine and intravenous flurbiprofen twice daily after surgery. Postoperative pain at rest and on coughing, postoperative morphine consumption, incidence of postoperative nausea and vomiting (PONV), pruritus and urinary retention, ambulation, and satisfaction score were recorded. Patients were assessed at 3 h after surgery and twice daily on postoperative days (POD) 1 and 2.

RESULTS

Data of 54 patients were analyzed. Compared to the TAP group (n = 27), pain score on coughing was significantly lower in the CWI group (n = 27) on POD1 and POD2 (P < 0.05). Pain score on coughing at 3 h after surgery, pain score at rest at all assessed time points, morphine consumption, incidence of PONV, pruritus and urinary retention, ambulation, and satisfaction score were not different between the two groups.

CONCLUSION

CWI reduced pain on coughing after the day of surgery compared with single-injection TAP block when performed as part of multimodal analgesia in patients undergoing gynecologic laparotomy.

The analgesic efficacy of continuous presternal bupivacaine infusion through a single catheter after cardiac surgery

Background:

Median sternotomy, sternal spreading, and sternal wiring are the main causes of pain during the early recovery phase following cardiac surgery.

Aim:

This study was designed to evaluate the analgesic efficacy of continuous presternal bupivacaine infusion through a single catheter after parasternal block following cardiac surgery.

Materials and Methods:

The total of 40 patients (American Society of Anesthesiologist status II, III), 45–60 years old, undergoing coronary – artery bypass grafting were enrolled in this prospective, randomized, double-blind study. A presternal catheter was inserted with continuous infusion of 5 mL/h bupivacaine 0.25% (Group B) or normal saline (Group C) during the first 48 postoperative hrs. Primary outcomes were postoperative morphine requirements and pain scores, secondary outcomes were extubation time, postoperative respiratory parameters, incidence of wound infection, Intensive Care Unit (ICU) and hospital stay duration, and bupivacaine level in blood.

Statistical Methods:

Student's t-test was used to analyze the parametric data and Chi-square test for categorical variables.

Results:

During the postoperative 48 h, there was marked reduction in morphine requirements in Group B compared to Group C, (8.6 ± 0.94 mg vs. 18.83 ± 3.4 mg respectively, P = 0.2), lower postoperative pain scores, shorter extubation time (117 ± 10 min vs. 195 ± 19 min, respectively, P = 0.03), better respiratory parameters (PaO₂/FiO_2, PaCO₂ and pH), with no incidence of wound infection, no differences in ICU or hospital stay duration. The plasma concentration of bupivacaine remained below the toxic threshold (at T24, 1.2 ug/ml ± 0.3 and T48 h 1.7 ± 0.3 ug/ml).

Conclusion:

Continuous presternal bupivacaine infusion has resulted in better postoperative analgesia, reduction in morphine requirements, shorter time to extubation, and better postoperative respiratory parameters than the control group.

Role of wound instillation with bupivacaine through surgical drains for postoperative analgesia in modified radical mastectomy

Background and Aims:

Modified Radical Mastectomy (MRM) is the commonly used surgical procedure for operable breast cancer, which involves extensive tissue dissection. Therefore, wound instillation with local anaesthetic may provide better postoperative analgesia than infiltration along the line of incision. We hypothesised that instillation of bupivacaine through chest and axillary drains into the wound may provide postoperative analgesia.

Methods:

In this prospective randomised controlled study 60 patients aged 45–60 years were divided into three groups. All patients were administered general anaesthesia. At the end of the surgical procedure, axillary and chest wall drains were placed before closure. Group C was the control with no instillation; Group S received 40 ml normal saline, 20 ml through each drain; and Group B received 40 ml of 0.25% bupivacaine and the drains were clamped for 10 min. After extubation, pain score for both static and dynamic pain was evaluated using visual analog scale and then 4^th hourly till 24 h. Rescue analgesia was injection tramadol, if the pain score exceeds 4. Statistical analysis was performed using SPSS version 13.

Results:

There was a significant difference in the cumulative analgesic requirement and the number of analgesic demands between the groups (P: 0.000). The mean duration of analgesia in the bupivacaine group was 14.6 h, 10.3 in the saline group and 4.3 h in the control group.

Conclusion:

Wound instillation with local anaesthetics is a simple and effective means of providing good analgesia without any major side-effects.

The pharmacokinetics and safety of an intraoperative bupivacaine-collagen implant (XaraColl(®)) for postoperative analgesia in women following total abdominal hysterectomy

Background

XaraColl^®, a collagen-based intraoperative implant that delivers bupivacaine to the site of surgical trauma, is under development for postoperative analgesia. We examined the pharmacokinetics, safety and efficacy of XaraColl following implantation in women undergoing total abdominal hysterectomy.

Methods

Three XaraColl implants, each containing 50 mg bupivacaine hydrochloride, were implanted in 12 women undergoing total abdominal hysterectomy for a benign condition. Serum samples were obtained through 96 hours for pharmacokinetic analysis. Patients received acetaminophen 1000 mg every 6 hours, diclofenac 50 mg every 8 hours, and were given access to intravenous morphine for breakthrough pain via patient-controlled analgesia during the first 24 hours. Pain intensity was assessed at regular intervals using a 100 mm visual analog scale. Safety was assessed through 30 days.

Results

The pharmacokinetic profile displayed a double peak in bupivacaine concentration with the second peak occurring up to 24 hours after the first and at a generally higher concentration. The time to maximum concentration (t_max) varied from 0.5 to 24 hours (median 12 hours) according to which peak predominated. The mean maximum concentration (C_max) was 0.22 μg/mL and the maximum individual C_max was 0.44 μg/mL, which are well below the established systemic toxicity threshold. Morphine use was generally low (mean 16.8 mg; median 6.5 mg) and compared favorably with institutional experience. At 6 hours post-surgery, 11 patients recorded pain scores ≤ 20 mm, 6 recorded ≤ 10 mm, and 2 reported no pain. Scores continued to decline throughout the study. The product was considered safe and well tolerated.

Conclusion

XaraColl exhibits a biphasic and sustained release profile that may provide a significant advance over standard wound infiltration. Considering the encouraging results from this study alongside those from other randomized controlled efficacy trials, XaraColl should be further evaluated as a postoperative analgesic in large, double-blind efficacy trials.

The effect of local anaesthetic on post-operative pain with wound instillation via a catheter for paediatric orthopaedic extremity surgery

PURPOSE

We aimed to investigate the effects on post-operative pain of local anaesthetic administration via a catheter placed into the operation site in patients who were undergoing upper and lower extremity paediatric orthopaedic surgery.

METHODS

In this randomised, double-blind and placebo study, 40 ASA I-II patients aged between 1 and 12 years were randomly allocated into two groups: study group (Group S: 0.2 ml/kg, 0.5% bupivacaine, n = 20) and control group (Group C: 0.2 ml/kg, serum physiologic, n = 20). Before the fascia was closed by the surgical team, the solution previously prepared by the chief nurse was injected into the subfascial soft tissue with the syringe as the "injected dose" of serum physiologic or bupivacaine. After the closure, 0.2 ml/kg (1 mg/kg) bupivacaine or saline was instillated as the "first instillated dose" into the surgical area via the catheter. Pain scores were recorded at 0, 1, 2, 4, 8, 12, 24 and 48 h post-operatively. Patients were administered 0.75 mg/kg meperidine intramuscularly post-operatively to equalise the pain scores.

RESULTS

No statistically significant difference was found between Group S and Group C in terms of demographic and other data and pain scores in the post-anaesthesia care unit, while a statistically significant decrease was found at 2, 4, 8, 12, 24 and 48 h in Group S and at 1, 2 and 4 h in Group C based on pain scores in the post-anaesthesia care unit (P < 0.05). A statistically significant decreasing pain score was found at 4, 8, 12, 24 and 48 h in Group S (P < 0.05).

CONCLUSION

The local anaesthetic administered via a catheter implanted in the surgical field may provide long-term and efficient post-operative analgesia.

Expression of granulocyte colony-stimulating factor is induced in injured rat carotid arteries and mediates vascular smooth muscle cell migration

Granulocyte colony-stimulating factor (G-CSF) is a lineage-restricted hematopoietic growth factor that stimulates proliferation and maturation of hematopoietic progenitors and is a known powerful mobilizer of bone marrow-derived stem cells. Very little has been reported on G-CSF expression and modulation of vascular smooth muscle cell (VSMC) activation. The purpose of this study was to characterize the expression and effects of G-CSF on primary human VSMC and balloon angioplasty-injured rat carotid arteries. In cultured human VSMC, G-CSF mRNA and protein expression are induced by several cytokines, with the most potent being fetal calf serum and T-lymphocyte-conditioned media. G-CSF is not expressed in naive rat carotid arteries but is induced in neointimal SMC in carotid arteries subject to balloon angioplasty. G-CSF is chemotactic for human VSMC. There is a significant difference between unstimulated cells and those treated with G-CSF at 100 and 1,000 pg/ml (P < 0.01 and 0.05 for 3 experiments). G-CSF also activates the GTPase Rac1, a regulator of cellular migration in VSMC. Inhibition of Rac1 inhibits G-CSF-driven VSMC migration. Important signal transduction protein kinases, including p44/42 MAPK, Akt, and S6 kinase, are also activated in response to G-CSF. This is the first report describing the expression of G-CSF in injured arteries and the multiple effects of G-CSF on VSMC activation. Together, our data suggest that G-CSF is an important mediator of inflammatory cell-VSMC communication and VSMC autocrine activation and may be an important mediator of the VSMC response to injury.