Continuous Wound Infiltration with Local Anesthetic Is an Effective and Safe Postoperative Analgesic Strategy: A Meta-Analysis

Introduction

Postoperative pain management is an essential module for perioperative care, especially for enhanced recovery after surgery programs. Continuous wound infiltration (CWI) with local anesthetic may be a promising postoperative analgesic strategy. However, its analgesic efficacy and safety remain debatable.

Methods

Embase and PubMed databases were systematically searched for relevant randomized controlled trials (RCTs). RCTs assessing the analgesic efficacy and safety of CWI with local anesthetic for postoperative analgesia were selected. The outcomes contained pain scores during rest and mobilization, total opioid consumption, time to the first request of rescue analgesia, length of hospital stay, satisfaction with analgesia, time to return of bowel function, postoperative nausea and vomiting, total complication, wound infection, hypotension, and pruritus. The weighted mean difference and risk ratio were used to pool continuous and dichotomous variables, respectively.

Results

A total of 121 RCTs were included. CWI with local anesthetic reduced postoperative pain during rest and mobilization at different time points, increased satisfaction with analgesia, shortened recovery of bowel function, and reduced postoperative nausea and vomiting compared with the placebo group, especially for laparotomy surgery. There were no significant differences in these clinical outcomes compared to epidural and intravenous analgesia. CWI with local anesthetic reduced the total opioid consumption and hypotension risk and did not increase total complications, wound infection, or pruritus. CWI with local anesthetic had a better analgesic efficacy without increased side effects for sternotomy surgery. However, CWI with local anesthetic did not translate into favorable analgesic benefits in laparoscopic surgery.

Conclusion

CWI with local anesthetic is an effective postoperative analgesic strategy with good safety profiles in laparotomy and sternotomy surgery, and thus CWI with local anesthetic may be a promising analgesic option enhancing recovery after surgery programs for these surgeries.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40122-021-00241-4.

Continuous wound infiltration (CWI) with local anesthetic may be a promising postoperative analgesic strategy, but its effect remains debatable. We performed this meta-analysis based on 121 high-quality articles (RCTs) to evaluate the analgesic efficacy and safety of CWI with local anesthetic. We found that CWI with local anesthetic could reduce postoperative pain, increase satisfaction with analgesia, shorten recovery of bowel function, and reduce postoperative nausea and vomiting, especially for laparotomy surgery. However, CWI with local anesthetic did not show favorable analgesic benefits in laparoscopic surgery.

Comparison of the postoperative effect between epidural anesthesia and continuous wound infiltration on patients with open surgeries: A meta-analysis

PURPOSE

The study aimed to compare the effect of epidural anesthesia (EA) and continuous wound infiltration (CWI) on surgical patients.

METHODS

The literature retrieval was conducted in relevant databases from their inception to June 2018 with the predefined searching strategy and selection criteria. Then, the Cochrane Collaboration's tool was used to assess the quality of included studies. In addition, odds ratio (OR) and standardized mean difference (SMD) with its corresponding 95% confidence interval (CI) were used as a measure of effect size for evaluating outcomes indicators.

RESULTS

Totally, sixteen RCTs were included. The incidence of hypotension in EA group was significantly higher than CWI group (OR = 3.7398; 95% CI: 1.0632 to 13.1555). In addition, EA provided better pain relief than CWI on rest at 72 h (SMD = -0.6037; 95% CI: -1.0767 to -0.1308) after surgery. Additionally, there were no significant differences in pain score on rest and mobilization at 2 h, 12 h, 24 h and 48 h. Moreover, the subgroup analysis showed that pain scores in EA group was significantly reduced at 2 h on rest and 12 h on mobilization than CWI group after liver resection surgery, as well as at 72 h on rest after colorectal surgery.

CONCLUSION

CWI is superior to EA with a lower incidence of complications for use in surgery, and EA may provide better pain control than CWI on pain relief after surgery.

Utility of percutaneous catheters for local anaesthetics infusion for postoperative pain control in lumbar arthrodesis. A prospective cohort study

OBJECTIVE

To evaluate whether postoperative continuous wound infiltration of levobupivacaine through two submuscular catheters connected to two elastomeric pumps after lumbar instrumented arthrodesis is more effective than intravenous patient-controlled analgesia.

MATERIAL AND METHODS

An observational, prospective cohorts study was carried out. The visual analogue scale, the need for additional rescue analgesia and the onset of adverse effects were recorded.

RESULTS

Pain records measured with visual analogue scale scale were significantly lower in the 48hours postoperative record at rest (p=.032). The other records of visual analogue scale showed a clear tendency to lower levels of pain in the group treated with the catheters. No statistically significant differences were found in the rescue analgesia demands of the patients. The adverse effects were lower in the catheter group (6 cases versus 11 cases) but without statistical differences.

CONCLUSIONS

A trend to lower pain records was found in the group treated with catheters, although differences were not statistically significant.

Post-operative effectiveness of continuous wound infiltration, continuous epidural infusion and intravenous patient-controlled analgesia on post-operative pain management in patients undergoing spinal surgery

BACKGROUND AND AIMS

Very few studies have compared continuous wound infiltration (CWI), continuous epidural infusion (CEI) and intravenous Patient Controlled Analgesia (PCA) with morphine in spine surgery. This study compared these modalities in patients undergoing microdissectomy.

METHODS

This prospective, randomized control trial was conducted on 75 patients of American Society of Anesthesiologists' physical status I or II undergoing microdiscectomy. Patients in all the three groups received morphine 1 mg IV, with a lockout period of 10 min after each bolus, and the maximum allowed dose was 15 mg/5 h postoperatively. Patients in Group A received CWI with 0.25% levobupivacaine 20 mL as bolus after extubation followed by infusion at 5 mL/h. Group B received CEI with 0.25% levobupivacaine at 5 mL/h. Patients in Group C received intravenous (IV) morphine by PCA pump only. The primary end points were static and dynamic visual analogue scores (VAS) and postoperative pain scores. Secondary observations were postoperative morphine consumption at 8 h, 24 h and 48 h, and patient satisfaction.

RESULTS

Group A showed greater analgesic effects at 12 h (P < 0.02), 24 h (P < 0.03), 36 h (P < 0.008) and 48 h (P < 0.007) when compared to the other two techniques, as pain scores were less in group A as compared to group B and C. The requirement of postoperative intravenous morphine (mg) was 18 ± 12.82, 22.92 ± 9.88, 41.56 ± 8.83 for groups A, B and C after 48 h (P < 0.001).

CONCLUSION

Continuous wound infiltration is an effective postoperative pain control technique with minimal side effects, after spinal surgery.

Influence of different positioning of a local pain catheter on postoperative pain after paramedian laparotomy-a blinded, randomized trial

BACKGROUND

Continuous application of local anaesthetics reduces postoperative pain after different approaches for laparotomy. In this randomized, blinded trial, we investigated the effect of continuous application of local anaesthetics after paramedian laparotomy either with subfascial or subcutaneous catheter in addition to a standardized systemic analgesia.

MATERIALS AND METHODS

Patients with stage III/IV melanoma and indication for radical iliac lymph node dissection (RILND) were randomized to a continuous application of a local anaesthetic through either a subfascial or subcutaneous catheter. Participants and those assessing the outcomes were blinded. The main outcome criterion was the pain level on the first postoperative morning while exercising measured with a visual analogue scale. Minor criteria were the pain measured by the area-under-curve until the third postoperative day, the patient's satisfaction with analgesic treatment, the analgesic requirement, the overall complications and the day of discharge.

RESULTS

Fifty-two patients were evaluated. Pain therapy was sufficient in both groups during the postoperative course while resting and during mobilization. There were no significant differences regarding the main and minor outcome criteria. Doses of additional analgesics did not differ between groups. No adverse events or side effects were observed.

CONCLUSION

For patients who undergo paramedian laparotomy, none of the investigated techniques is superior to the other at a median pain level under visual analogue scale (VAS) 30 mm on the first postoperative morning.

TRIAL REGISTRATION NUMBER

DRKS00003632 (German Register of Clinical Trials).

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.